Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants

Anterior-apical Transvaginal Mesh (Calistar-S) for Treatment of Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year

INTRODUCTION AND HYPOTHESIS

Calistar-S is a single-incision synthetic mesh kit that addresses apical and anterior compartment prolapse. The aims of this study were to evaluate the short-term objective and subjective outcomes at the 1-year follow-up. The secondary objectives were to evaluate quality of life and lower urinary tract symptoms (LUTS) outcomes, as well as surgical complications.

METHODS

Records of 108 patients with symptomatic advanced pelvic organ prolapse (stages III and IV) who underwent prolapse surgery using the Calistar-S system from June 2018 to August 2022 were reviewed. The primary outcome was the objective cure of anterior and apical prolapse < stage 1, and the subjective cure was the negative response to questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory-6. Secondary outcomes measured quality of life, the presence of lower urinary tract symptoms, and complications.

RESULTS

A total of 101 patients were evaluated. The overall objective cure rate is 97% and the subjective cure rate is 92.1%. Good outcomes were seen in all three compartments. Secondary outcomes show significant improvement in all validated questionnaires. Persistence and de novo urinary incontinence were 15.2% and 18.2% post-operatively. There is one case of bladder injury and one case of vaginal mesh exposure.

CONCLUSIONS

The Calistar-S System is a safe and efficient method for treating advanced-stage POP. We observed good anatomical results and subjective relief with a minimal complication rate. LUTS have also been positively affected, showing a high success rate. Additional studies are needed to establish the long-term efficacy of this system.

Polypropylene anterior-apical single-incision UPHOLD-LITE mesh surgery in women with severe pelvic organ prolapse: Outcome at 53 months follow up

BACKGROUND AND PURPOSE

We present this current study to complement with mesh inlays plausible benefits (UPHOLD-LITE System) on available long-term study amidst FDA's concern on mesh complications. This study aims to assess the medium-term outcomes of UPHOLD-LITE system for treatment of advanced pelvic organ prolapse (POP) and its complications, and lower urinary tract symptoms.

METHODS

This is a retrospective case series of 53 months follow-up of 123 consecutive patients who underwent UPHOLD-LITE system. Objective outcome measures the anatomical correction of prolapse with POP-Q ≤ Stage 1. Subjective outcome was patient's feedback to questions 2 and 3 of POPDI-6. Secondary outcome measures the quality of life, presence of lower urinary tract symptoms and complications. Quality of life is assessed by validated questionnaires on Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 (PISQ-12) at 1 and 3 years post-operatively.

RESULTS

Objective outcome at 1 and 3 years was at 96.7 % and 95.4 % respectively. The subjective cure was 95.1 % and 91.6 %. Five-year cumulative cure rate maintained at 87.2 %. Secondary outcomes observed improvement on UDI-6, IIQ-7, POPDI-6 and PISQ-12 postoperatively. Bladder outlet obstruction improved while de novo urodynamic stress incontinence (USI) increased slightly post surgically. Mesh erosion rate was 0.8 %.

CONCLUSION

The UPHOLD-LITE system demonstrated good medium term anatomical correction of apical and anterior prolapse, with good subjective cure and improved quality of life. Whilst complication rate was low, slight increase in de novo USI was observed.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT

The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue.

OBJECTIVE

To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data.

EVIDENCE ACQUISITION

PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed.

EVIDENCE SYNTHESIS

Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE).

CONCLUSIONS

Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence.

PATIENT SUMMARY

In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

Efficacy and safety of anterior vaginal prolapse treatment using single incision repair system: Multicentric study

OBJECTIVE

Up to 80% of all POP surgical procedures are due to anterior vaginal wall prolapse. The aim of this study is to evaluate the efficacy and safety of transvaginal anterior mesh for POP surgical repair.

MATERIALS AND METHODS

153 consecutive patients with symptomatic or recurrent anterior vaginal prolapse undergoing surgical single-incision mesh (Calistar S) were prospectively enrolled in the study. Preoperative evaluation was performed collecting urogynecological history and performing a clinical exam, 3-day voiding diary and urodynamic testing. All incontinent patients completed the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF). Operative time, blood loss, perioperative and postoperative complications were prospectively recorded. Postoperative follow-up was scheduled at 1, 6, and 12 months with a urogynecological interview and examination. Success rate was assessed at 1, 6 and 12 months postoperatively.

RESULTS

The median follow-up was 16.4 months. None of patients had intraoperative complications. Eight patients (5%) required surgical intervention for complications (5 patients (3%) for haematoma and 3 (2%) for vaginal erosion). At 12 months of follow up 130 out of 140 patients (93%) gained the subjective cure criterion, while 129 out of 140 patients (92%) obtained the objective cure criterion. Eleven (7.8%) patients experienced stage 2 or higher prolapse recurrence and three of them with a stage ≥3 underwent reintervention. No significant differences were recorded in primary outcome at 1, 6 or 12 months postoperatively.

CONCLUSIONS

Anterior compartment prolapse repair by Calistar S (single-incision vaginal mesh) is an effective and safe procedure without significant complications.

Reoperation Rates of Stress Incontinence Surgery in Rural versus Urban Hospitals

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

The effect evaluation of traditional vaginal surgery and transvaginal mesh surgery for severe pelvic organ prolapse: 5 years follow-up

The objective of this study was to compare the clinical effectiveness of traditional vaginal surgery and transvaginal mesh (TVM) surgery on severe pelvic organ prolapse (POP). We performed a retrospective chart review study of 258 severe POP patients who underwent surgery between November 2010 and September 2016. One hundred forty patients underwent traditional vaginal surgery and 118 TVM surgery. The Pelvic Organ Prolapse Quantitation (POP-Q) staging was used for objective evaluation. The Pelvic Floor Distress Inventory-20 (PFDI-20), Pelvic Floor Disease Life Impact Questionnaire Simplified Version-7 (PFIQ-7), and Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire (PISQ-12) were used for subjective evaluation. Their complications were also recorded. All the data were collected in the outpatient department through the follow-up at 3 months, 1, 3, and 5 years after the operation. Forty patients in the traditional vaginal surgery group and 25 in the TVM group were lost to follow-up. There was no difference in the POP-Q score between the groups (P = 0.346). The recurrence rate increased with follow-up time, reaching nearly 20% in the two groups by 5 years. The TVM group has higher PFDI-20 and PFIQ-7 scores and lower PISQ-12 scores than the traditional vaginal surgery group at six months, 1, 3, and 5 years, respectively (P < 0.001). Mesh exposure has occurred in the TVM group. Both surgeries showed similar objective satisfaction and recurrence rate. However, traditional vaginal surgery has higher subjective satisfaction than TVM in our study and does not risk exposure to prosthetic material.

Incidence of Midurethral Sling Revision or Removal by Its Timing With Prolapse Surgery

OBJECTIVE

The aim of the study was to evaluate incidence of midurethral sling removal/revision based on timing with surgery for pelvic organ prolapse.

METHODS

This was a retrospective cohort study of women who underwent midurethral sling placement in a claims-based database of women 65 years or older. Three groups were identified using the Current Procedural Terminology codes: (1) isolated sling, (2) concomitant sling, and (3) prolapse surgery and staged sling after prolapse surgery. In the staged group, placement of sling was identified within 18 months after index prolapse surgery. Fascial grafts were excluded. Sling removal/revision was identified across 3 years after sling surgery using Current Procedural Terminology code 57287. Rates of sling removal/revision were calculated by group. Comparisons were made using the χ2 test and analysis of variance. Cumulative incidence of removal/revision was evaluated using the Kaplan-Meier curves. Cox proportional hazards was performed to evaluate factors influencing removal/revision.

RESULTS

We identified 39,381 isolated MUSs, 25,389 concomitant, and 886 staged. The rate of sling removal/revision was 3.52%. Rates of removal/revision differed between groups (7% staged vs 3.94% concomitant vs 3.17% isolated sling, P < 0.001). Compared with the staged group, the rate of removal/revision was lower in the isolated sling group (relative risk, 0.4550; 95% confidence interval [CI], 0.358-0.568) and the concomitant group (relative risk, 0.5666; 95% CI, 0.4450-0.7287). After adjusting for patient characteristics, sling revision or removal remained significantly less in the isolated MUS (hazard ratio, 0.50; 95% CI, 0.39-0.65) and concomitant (odds ratio, 0.55; 95% CI, 0.43-0.71) groups.

CONCLUSIONS

Sling removal/revision is higher when it is staged after prolapse surgery compared with isolated and concomitant placement. Future studies are needed to confirm these findings in a controlled population.

Symptomatic improvement after mesh removal: a prospective longitudinal study of women with urogynaecological mesh complications

OBJECTIVE

To compare clinical characteristics and outcomes in patients undergoing excision of polypropylene urogynaecological mesh for pain, mesh exposure or both.

DESIGN

Prospective, longitudinal cohort.

SETTING

Academic tertiary referral centre.

POPULATION

Women undergoing complete vaginal mesh excision for mesh exposure and/or pain.

METHODS

Clinical and patient-reported outcomes assessing pain (visual analog scale, VAS), bother (Pelvic Floor Distress Inventory, PFDI) and functional impact (Pelvic Functional Impact Questionnaire, PFIQ) were collected at baseline, 6, 12 and 24 months after complete mesh excision. Outcomes were compared by mesh type (sling, prolapse [transvaginal or sacrocolpopexy mesh], both) and complication (pain, exposure, both).

MAIN OUTCOME MEASURES

'Much better' or 'Very much better' on Patient Global Impression of Improvement (PGI-I) up to 2 years after removal.

RESULTS

Of 173 women, 48 underwent removal for pain, 27 for exposure and 98 for exposure plus pain. 'Moderate to severe' baseline symptoms were reported by 75%; the most prevalent and severe symptom was dyspareunia. Patients with pain alone were most bothered (PFDI median 234.2, interquartile range 83, P = 0.02) and had the highest functional impact (PFIQ median 181, interquartile range 138, P < 0.001). After excision, only 33.3% of women with pain alone reported 'improved' symptoms (PGI-I), versus 73.9% with exposure, 58.3% with exposure plus pain (P = 0.03) with no differences in PGI-I by mesh type. VAS scores decreased in all groups, but PFDI and PFIQ did not improve in pain patients.

CONCLUSIONS

In women experiencing a pain complication after urogynaecological mesh insertion, mesh removal often does not improve symptoms.

TWEETABLE ABSTRACT

Only 33% of women with pain complications have improved symptoms after urogynaecological mesh removal.

The Burden of Reoperations and Timeline of Problems in 1,530 Cases of Mesh-Related Complications

BACKGROUND

Mesh-related complications resulting from pelvic organ prolapse (POP) reconstruction operations may be a devastating experience leading to multiple and complex interventions.

OBJECTIVES

The aim of the study was to describe the experience and time frame of management of mesh-related complications in women treated for POP or stress urinary incontinence in a tertiary center.

METHODS

1,530 cases of mesh-related complications were accessed regarding their clinical presentation, number of surgeries, and timeline of surgical treatments to treat multiple clinical complaints until the ultimate operation where all the meshes were removed in a single tertiary center.

RESULTS

The studied population revealed to be a highly referred one with only 10.2% of the cases implanted at our center. Clinical presentation varied widely with 48.7% referring pain as the chief complaint, while 31.3% complained of voiding dysfunctions, 2.5% reported genital prolapses, 2.2% complained of vaginal problems, and 1.2% noted intestinal problems as the main clinical complaint. Only 4.8% of the cases presented mesh erosion at examination; 57.8% of the cases required more than 1 operation to address the mesh-related problems. Sixty-eight cases had more than 10 operations up to complete removal. Three clusters of patients could be identified: (i)-those from whom the mesh was promptly removed after clinical problems emerged, (ii) those with slowly evolving problems, and (iii) those with escalating problems despite treatment attempts.

CONCLUSIONS

Mesh-related complications after pelvic floor reconstruction are an evolving disease with diverse clinical presentation. The identified time-related problems and the multiple failed attempts to treat their complications warrant attention with continuous monitoring of these patients and aggressive removal of the mesh if the clinical complaint cannot be swiftly managed.

The impact of midurethral sling surgery on the development of urinary tract infections

PURPOSE/OBJECTIVE

To measure the impact of the placement of a midurethral sling (MUS) on development of urinary tract infections (UTI) in women with stress urinary incontinence.

METHODS

This is an analysis of a large managed care organization MUS database from 2005 to 2016. The database was queried to identify UTI and diagnosis of recurrent UTI. The primary outcome was the UTI rate after MUS. Secondary outcomes included the recurrent UTI rate and rates of UTI over time.

RESULTS

Over the study period, 13,404 MUS were performed. In the 12 postoperative months, 23% of patients developed a UTI, while 4% developed a de novo recurrent UTI diagnosis. UTIs were most frequently diagnosed in the 1st month, with the 7th postoperative day the most common. Predictors of UTI development included increased age (OR 3.69 [95% CI 2.58-5.26]), being diabetic (OR 1.43 [95% CI 1.28-1.60]), and having urinary retention requiring prolonged catheterization (OR 2.45 [95% CI 2.11-2.85]). UTIs were less likely to be diagnosed in those with transobturator MUS (OR 0.85 [95% CI 0.78-0.94]). Patients who developed a UTI were more likely to have a reoperation (p = 0.0147), including a reoperation for mesh revision/removal (p = 0.0287), and recurrent SUI (p = 0.0394). Patients who developed a UTI were more likely to develop postoperative de novo urgency urinary incontinence (UUI) (p < 0.0001).

CONCLUSION

Patients are at risk of UTI and rUTI after MUS. Risk of developing UTIs decreases with time. Predictors of developing UTI can help surgeons in the care of patients after MUS.

Complications of Pelvic Organ Prolapse Surgery in the 2015 Finnish Pelvic Organ Prolapse Surgery Survey Study

OBJECTIVE

To describe the major complications of pelvic organ prolapse (POP) surgery in Finland.

METHODS

The Finnish Pelvic Organ Prolapse Surgery Survey 2015 study is a prospective cohort of POP surgeries performed in Finland in 2015. Perioperative, postoperative, and late complications during 1 year of follow-up were compared among native tissue repair, transvaginal mesh, and abdominal mesh surgery. Major complications were assessed using the Clavien-Dindo grading system. Predictive factors for major complications were studied with logistic regression analysis.

RESULTS

Within 1 year after POP surgery, 396 (11.2%) of 3,515 women had at least one complication: 10.9% after native tissue, 11.7% after transvaginal mesh, and 13.5% after abdominal mesh repair. The majority of complications occurred within 2 months after surgery and postoperative infection (4.3%) and bleeding or hematoma (2.6%) were the most frequent. The incidence of organ injuries was low. Mesh-augmented surgery was associated with significantly higher rates of bladder and bowel injuries than native tissue surgery. Complication-related reoperations occurred significantly more often after abdominal mesh repair than native tissue surgery (5.2% vs 1.8%, P=.001). Mesh-related complications were diagnosed more often after transvaginal mesh repair. The overall rate of major complications (Clavien-Dindo grades III-V) was 3.3%. Abdominal mesh surgery was associated with the highest rate of major adverse events (8.8% vs native tissue repair 2.6% and transvaginal mesh 4.9%). The incidence of Clavien-Dindo grade IV or V complications was rare (less than 0.6%). Mesh surgery (transvaginal mesh adjusted odds ratio [aOR] 2.23, 95% CI 1.31-3.80, and abdominal mesh aOR 3.02, 95% CI 1.67-5.46), longer operating time (aOR 2.84, 95% CI 1.78-4.53), prior POP surgery (aOR 1.68, 95% CI 1.00-2.81) and difficult surgery (aOR 2.75, 95% CI 1.63-4.62) were associated with an increased risk for occurrence of major complications.

CONCLUSION

Serious adverse events were rare regardless of the operative approach. However, mesh-augmented surgery was associated with higher risk for major complications.

Clinical analysis of pain after transvaginal mesh surgery in patients with pelvic organ prolapse

BACKGROUND

The purpose of this study was to investigate the relevant factors of pain after transvaginal mesh (TVM) surgery for the treatment of pelvic organ prolapse and to analyse the management and relief of the pain.

METHODS

A multicentre retrospective study of a clinical database of patients who underwent TVM surgery was conducted, and pain related aspects were analysed.

RESULTS

A total of 1855 patients were included in the study. We divided the patients into two groups: pain-free (1805 patients) and pain (50 patients) group. The incidence of pain after TVM surgery was 2.70%, with a median occurrence time of 7.5 months. Pain mainly involved the vagina, perineum, buttocks, groin, inner thighs, and lower abdomen. Excessive intraoperative blood loss (OR = 1.284, 95% CI 0.868-2.401) and postoperative anatomic failure (OR = 1.577, 95% CI 0.952-3.104) were analysed as risk factors with statistical significance. Mesh exposure rate in the pain group was 38%, showing a significant difference between the groups (P < 0.01). Forty patients underwent non-surgical treatment, with a relief rate of 40.0%, 33 patients received surgical treatment, 15 underwent partial mesh removal, and 18 underwent complete mesh removal, with a relief rate of 84.8%. The total relief rate was 88% within all 50 patients suffering from pain.

CONCLUSIONS

Excessive intraoperative bleeding and unsatisfactory postoperative anatomic outcomes can increase the risk of postoperative pain; mesh exposure is also associated with the pain. Most patients can get pain relief with proper management, more than half of whom may need mesh removal with differing approach.

Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling

Introduction

Patients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.

Objective

The primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.

Methods

From 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant.

Results

About 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).

Conclusion

In conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review

BACKGROUND

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery.

METHODS

A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries.

RESULTS

Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days.

CONCLUSIONS

The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Multidimensional outcomes of suburethral synthetic midurethral sling removal

PURPOSE

To report multidimensional outcomes encompassing pain, dyspareunia, and recurrent urinary tract infections (UTIs), following suburethral sling removal (SSR) of synthetic midurethral slings (MUS) placed for female stress urinary incontinence.

METHODS

We reviewed a prospectively maintained, IRB-approved database of women undergoing SSR at our institution. Demographic data, type of sling, and symptoms along with Urogenital Distress Inventory-Short Form (UDI-6) scores both before and after SSR were analyzed. Success was defined using several modalities including patient-reported symptoms (ideal outcome) and UDI-6 questionnaire.

RESULTS

From 3/2006-2/2017, 443 women underwent SSR of which 230 met study criteria with median overall follow-up of 23 months (mean 30 months). 180/230 (78%) patients reported 3 or more symptoms at presentation. Median most recent post-SSR total UDI-6 score was 38 vs. 50 at baseline (p < 0.0001). By UDI-6, 53% of patients achieved success post-SSR. An ideal outcome was attained in 22/230 (10%) patients. A modified outcome allowing for one minimally invasive anti-incontinence procedure and excluding sexual activity classified 112/230 (49%) patients as successes.

CONCLUSIONS

While patients with MUS present with multiple symptoms, following SSR, there is sustained improvement in multiple symptom domains, including pain and urinary incontinence. Allowing for minimally invasive anti-incontinence procedures (not inclusive of subsequent suburethral sling), the rate of success was 49%, which was comparable to that derived from UDI-6 scores (53%).

Surgeon volume and reoperation risk after midurethral sling surgery

BACKGROUND

Emerging research supports that fewer complications occur in patients who undergo surgery by higher surgical volume surgeons. The midurethral sling surgery has been involved in recent warnings and litigation, which further supports a need to understand features that enhance its safety and efficacy.

OBJECTIVE

The purpose of this study was to measure the impact of a surgeon's volume on their patient's rate of reoperation after midurethral sling surgery.

STUDY DESIGN

This was a retrospective cohort study that evaluated all surgeons who performed synthetic mesh midurethral sling surgery for stress urinary incontinence at a large managed care organization with >4.5 million members from 2005-2016. Physicians Current Procedural Terminology and International Classification of Diseases, version 9/10, codes were used to identify the procedures and the reoperations that were performed. The system-wide medical record was queried for demographic and perioperative data. The primary outcome was the overall reoperation rate after midurethral sling surgery. Concentration curves were used to identify the impact of a surgeon's surgical volume on their rate of reoperation. Demographics, characteristics, and reoperation of patients were compared with the use of chi-square test for categoric variables and Wilcoxon rank sum test for continuous variables. Poisson regression models with a robust error variance were used to calculate the unadjusted and the adjusted risk ratios of reoperation with the use of age, body mass index, marital status, race, parity, vaginal estrogen use, sling type, smoking, diabetes mellitus, and menopausal status as covariates.

RESULTS

Two hundred twenty-seven surgeons performed 13,404 midurethral sling surgeries over the study period; patients had a mean of 4.4 years of follow up. Higher-volume surgeons (>40 procedures/year, ≥95th percentile) performed 47% of the surgeries in this cohort and had an overall lower rate of reoperation (3.6% vs 4.2%; 95% confidence interval, 0.67-0.94; P=.04) compared with lower-volume surgeons. Higher-volume surgeons had a lower rate of reoperation for surgical failure (2.7% vs 3.6%; 95% confidence interval, 0.55-0.92; P<.01). Rates of reoperation for complications were similar between the 2 groups (1.1% vs 0.9%; 95% confidence interval, 0.82-1.13; P=.32). For patients whose condition required a reoperation secondary to complication, the rates of reoperation for urinary retention (0.9% vs 0.6%; P=.06), mesh exposure (0.2% vs 0.3%; P=.31), hemorrhage/bleeding (0.1% vs 0.0%; P=.11), pain (0.1% vs 0.1%; P=.52), and infection (0.0% vs 0.0%; P=.37) did not differ between higher- and lower-volume surgeons. The risk ratio for reoperation that compared higher- and lower-volume surgeons was 0.83 (95% confidence interval, 0.67-0.98; P=.01) in the adjusted model.

CONCLUSION

Although the reoperation rates were low for both higher- and lower-volume surgeons, higher-volume surgeons had lower overall rates of reoperation after midurethral sling surgery. This effect is seen most dramatically in reoperation for surgical failure, in which patients who have surgery with a higher-volume surgeon are 25% less likely to have postoperative stress urinary incontinence that leads to reoperation.

Do Pelvic Organ Prolapse Quantification Examination Ba and D Guide the Selection of Operation for Severe Pelvic Organ Prolapse?

Purpose: To determine whether the preoperative Ba and D point could help to guide the choice of surgical procedure for POP. Materials and Methods: This prospective cohort study included 250 subjects with anterior/apical defect from January 2012 to June 2015. All subjects underwent a complete preoperative evaluation and completed 12 months of follow-up. Based on the connection of preoperative Ba and D point of Pelvic Organ Prolapse Quantification (POP-Q), patients were assigned two groups: 137 patients who underwent anterior vaginal repair with mesh (AVM) and 113 patients who underwent AVM combined with sacrospinous ligament fixation (SSLF). The primary outcomes were anatomical cure and recurrence rate of both procedures. Secondary outcomes were prolapse symptom, quality of life and sexual function based upon validated questionnaires. The complications were also recorded in both groups. Results: Both groups were homogeneous preoperatively. The anatomical success rates for the anterior, apical and posterior vaginal compartments were 99.2%, 97.0% and 97.7% in the AVM group, respectively. For patients who underwent AVM-SSLF, the anatomical success rates for the anterior, apical and posterior compartments were 96.1%, 98.1% and 98.1%, respectively. The recurrence for both techniques was low. Both procedures presented a significant improvement with regard to postoperative quality of life (QOL), prolapse symptoms, and sexual function after 1-year follow-up. Conclusion: The preoperative Ba and D point correlated with surgical choice for the treatment of anterior/apical prolapse, which further decided the surgical outcomes for prolapse support.

Recurrence of Stress Urinary Incontinence After Midurethral Sling Revision: A Retrospective Cohort Study

OBJECTIVES

The primary objective is to determine the relative risk (RR) of reoperation for stress urinary incontinence (SUI) recurrence after midurethral sling (MUS) division or excision. Our secondary objective is to determine the RR of SUI symptom recurrence according to differing techniques of revision.

METHODS

This is a retrospective cohort study of all women who underwent surgical revision of an MUS by the Division of Urogynecology at the Women & Infants' Hospital during a 10-year period between October 1, 2004, and October 1, 2014. Sling division technique separates the sling from the urethra enough to permit transection either in the midline or lateral to the urethra. Revision was categorized as excision if a portion or the entirety of the sling was removed. Patients who underwent any operative procedure for SUI after revision were considered to have received reoperation. Subjectively, patients were considered to have postrevision recurrence of SUI if it was reported during routine evaluation/interviews or in the incontinence severity index questionnaire.

RESULTS

There were 102 patients who underwent revision of a type 1 mesh MUS; 45 underwent sling division, and 57 underwent mesh excision. After sling division, 4.4% of the patients underwent reoperation for recurrent SUI compared with 28.1% after sling excision (RR, 0.16; 95% confidence interval, 0.04-0.65). Stress urinary incontinence symptoms recurred in 13% after sling division versus 56% after excision (RR, 0.24; 95% confidence interval, 0.11-0.52).

CONCLUSIONS

The choice of technique may be dictated by the clinical scenario, but in situations in which sling division is an option, repeat operations and symptoms of SUI occur less frequently.

Incontinence rates after midurethral sling revision for vaginal exposure or pain

BACKGROUND

Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure.

OBJECTIVE

We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency.

STUDY DESIGN

This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence.

RESULTS

In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P = .03) and long-term (7% vs 59%, P = .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P = .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively (P = .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal.

CONCLUSION

In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.

Vaginal Mesh in Pelvic Reconstructive Surgery: Controversies, Current Use, and Complications

In 2001, the Food and Drug Administration approved the first surgical mesh product specifically designed for the surgical repair of pelvic organ prolapse and between 2004 and 2008, the use of vaginal mesh in gynecologic surgery was at its peak. Unfortunately, the rise in transvaginal mesh use was accompanied by a surge of adverse events and mesh-related complications. As a result, the Food and Drug Administration put forth several efforts to regulate the manufacturing of vaginal mesh products. These notifications have been supported by several gynecologic societies, and recommendations now exist not only on the placement of mesh and patient selection, but also on the evaluation and management of mesh-related complications. In addition, data on outcomes following management of these complications are now emerging.

In vitro differentiation of endometrial regenerative cells into smooth muscle cells: Α potential approach for the management of pelvic organ prolapse

Pelvic organ prolapse (POP), is a common condition in parous women. Synthetic mesh was once considered to be the standard of care; however, the use of synthetic mesh is limited by severe complications, thus creating a need for novel approaches. The application of cell-based therapy with stem cells may be an ideal alternative, and specifically for vaginal prolapse. Abnormalities in vaginal smooth muscle (SM) play a role in the pathogenesis of POP, indicating that smooth muscle cells (SMCs) may be a potential therapeutic target. Endometrial regenerative cells (ERCs) are an easily accessible, readily available source of adult stem cells. In the present study, ERCs were obtained from human menstrual blood, and phase contrast microscopy and flow cytometry were performed to characterize the morphology and phenotype of the ERCs. SMC differentiation was induced by a transforming growth factor β1-based medium, and the induction conditions were optimized. We defined the SMC characteristics of the induced cells with regard to morphology and marker expression using transmission electron microscopy, western blot analysis, immunocytofluorescence and RT-PCR. Examining the expression of the components of the Smad pathway and phosphorylated Smad2 and Smad3 by western blot analysis, RT-PCR and quantitative PCR demonstrated that the 'TGFBR2/ALK5/Smad2 and Smad3' pathway is involved, and both Smad2 and Smad3 participated in SMC differentiation. Taken together, these findings indicate that ERCs may be a promising cell source for cellular therapy aimed at modulating SM function in the vagina wall and pelvic floor in order to treat POP.

Outcomes of Autologous Fascia Pubovaginal Sling for Patients with Transvaginal Mesh Related Complications Requiring Mesh Removal

PURPOSE

We reviewed the outcomes of the autologous fascial pubovaginal sling as a salvage procedure for recurrent stress incontinence after intervention for polypropylene mesh erosion/exposure and/or bladder outlet obstruction in patients treated with prior transvaginal synthetic mesh for stress urinary incontinence.

MATERIALS AND METHODS

In a review of surgical databases at 2 institutions between January 2007 and June 2013 we identified 46 patients who underwent autologous fascial pubovaginal sling following removal of transvaginal synthetic mesh in simultaneous or staged fashion. This cohort of patients was evaluated for outcomes, including subjective and objective success, change in quality of life and complications between those who underwent staged vs concomitant synthetic mesh removal with autologous fascial pubovaginal sling placement.

RESULTS

All 46 patients had received at least 1 prior mesh sling for incontinence and 8 (17%) had received prior transvaginal polypropylene mesh for pelvic organ prolapse repair. A total of 30 patients underwent concomitant mesh incision with or without partial excision and autologous sling placement while 16 underwent staged autologous sling placement. Mean followup was 16 months. Of the patients 22% required a mean of 1.8 subsequent interventions an average of 6.5 months after autologous sling placement with no difference in median quality of life at final followup. At last followup 42 of 46 patients (91%) and 35 of 46 (76%) had achieved objective and subjective success, respectively. There was no difference in subjective success between patients treated with a staged vs a concomitant approach (69% vs 80%, p = 0.48).

CONCLUSIONS

Autologous fascial pubovaginal sling placement after synthetic mesh removal can be performed successfully in patients with stress urinary incontinence as a single or staged procedure.

Synthetic Graft Augmentation in Vaginal Prolapse Surgery: Long-Term Objective and Subjective Outcomes

OBJECTIVE

To report long-term objectives and subjective outcomes in women who underwent prolapse surgery with a synthetic graft augmentation.

DESIGN

Retrospective analysis (Canadian Task Force classification II-3).

SETTING

University hospital in the southeastern United States.

PATIENTS

Women with symptomatic pelvic organ prolapse who underwent transvaginal graft augmentation using the Prolift mesh system between July 2006 and December 2008 for a minimum 5-year follow-up.

INTERVENTIONS

Subjects completed the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), and the Patient Satisfaction Questionnaire. Subjects also underwent postoperative physical examination with Pelvic Organ Prolapse Quantification (POP-Q) and vaginal pain/stricture assessment. Long-term postoperative findings were compared with preoperative baseline data.

MEASUREMENTS AND MAIN RESULTS

Of 208 eligible subjects, 70 completed the questionnaires only, and 48 of these 70 provided both postoperative examination and questionnaire data. The mean duration of follow-up was 7.0 ± 0.7 years (range, 5.8-8.1 years). POP-Q measurements of Ba (point B anterior), Bp (B posterior), C (cervix), GH (genital hiatus), PB (perineal body), and overall pelvic organ prolapse stage were significantly improved (all p < .001 except for PB, p = .006). PFIQ-7 (total, Urinary Impact Questionnaire, and Pelvic Organ Prolapse Impact Questionnaire) and PFDI-20 (total, Urinary Distress Inventory, and Pelvic Organ Prolapse Distress Inventory) scores significantly improved (all p < .001). No differences were noted in the colorectal-anal subscales (Colorectal-Anal Impact Questionnaire and Colorectal-Anal Distress Inventory) and PISQ scores at >5-year follow-up (all p > .05). Satisfaction rates were 15.7% for not at all, 35.7% for somewhat, and 48.6% for completely satisfied. Complications included graft exposure (n = 3; 6%) and dyspareunia (n = 25; 36%).

CONCLUSION

Women undergoing transvaginal prolapse surgery using a synthetic graft continue to have positive objective and subjective outcomes, leading to significantly improved quality of life at a minimum 5-year follow-up.

Long term subjective cure rate, urinary tract symptoms and dyspareunia following mesh augmented anterior vaginal wall prolapse repair

INTRODUCTION

The aim of this study was to assess patient-centered long term outcomes following anterior vaginal repair with mesh.

METHODS

In January 2015, we identified 124 women who underwent anterior pelvic floor repair with mesh between January 2006 and February 2009. Patient records were reviewed and demographic, clinical, intra-operative and post-operative follow-up data retrieved. Telephone interviews were conducted to access information on clinical outcomes. Associations between baseline characteristics and long term symptoms were assessed by multivariable logistic regression models.

RESULTS

Seventy-nine women were reached and consented to participate. Patients were interviewed 79-104 months after surgery. Their mean age at the time of surgery was 62.48 ± 9.53 years; all had stage III cystocele with a mean POP Q point Ba of 5.32 ± 1.47. Twenty-four (30%) had a previous hysterectomy and 26 (33%) had a previous pelvic organ prolapse or stress urinary incontinence operation. At telephone interviews, recurrence of prolapse symptoms was reported by 11 (13.9%) patients, mostly in the posterior compartment. Only 6 needed a corrective procedure. One patient had her mesh removed due to dyspareunia. Eleven (13.9%) reported lower urinary tract symptoms other than prolapse, as follows: stress urinary incontinence (1), overactive bladder (8) and dyspareunia (2).

CONCLUSION

Long term rates of recurrent prolapse, dyspareunia and lower urinary tract symptoms were low for patients who underwent anterior vaginal wall mesh augmentation surgery for symptomatic cystoceles.

Tension-free polypropylene mesh-related surgical repair for pelvic organ prolapse has a good anatomic success rate but a high risk of complications

BACKGROUND

Food and Drug Administration announcements have highlighted the standard rate of mesh-related complications. We aimed to report the short-term results and complications of tension-free polypropylene mesh (PROSIMA™) surgical repair of pelvic organ prolapse (POP) using the standard category (C), timing (T), and site (S) classification system.

METHODS

A prospective cohort study of 48 patients who underwent PROSIMA™ mesh kit-related surgical repairs were followed for two years at Peking Union Medical College Hospital. Recurrence was defined as symptomatic POP quantification (POP-Q) Stage II or higher (leading edge ≥ -1 cm). The Patient Global Impression of Change Questionnaire, the Chinese version of the Pelvic Floor Impact Questionnaire short-form-7 and POP/Urinary Incontinence Sexual Questionnaire short-form-12 were used to evaluate the self-perception and sexual function of each patient. Mesh-related complications conformed to the International Urogynecological Association/International Continence Society joint terminology. The paired-sample t-test, one-way analysis of variance, Fisher's exact test, Kaplan-Meier survival analysis and log-rank test were used to analyze data.

RESULTS

All patients were followed up for ≥12 months; 30 (62.5%) patients completed the 24 months study. We observed a 93.8% (45/48) positive anatomical outcome rate at 12 months and 90.0% (27/30) at 24 months. Recurrence most frequently involved the anterior compartment (P < 0.05). Pelvic symptoms improved significantly from baseline (P < 0.05), although the patients' impressions of change and sexual function were not satisfying. Vaginal complication was the main complication observed (35.4%, 17/48). The survival analysis did not identify any relationship between vaginal complication and anatomical recurrent prolapse (POP-Q ≥ Stage II) (P = 0.653).

CONCLUSIONS

Tension-free polypropylene mesh (PROSIMA™ )-related surgical repair of POP has better short-term anatomical outcomes at the apical and posterior compartments, but a low patient satisfaction rate. The mesh complications were not the definitive cause of recurrence.

Management of Mesh Complications after SUI and POP Repair: Review and Analysis of the Current Literature

Purpose. To evaluate the surgical treatment concepts for the complications related to the implantation of mesh material for urogynecological indications. Materials and Methods. A review of the current literature on PubMed was performed. Results. Only retrospective studies were detected. The rate of mesh-related complications is about 15–25% and mesh erosion is up to 10% for POP and SUI repair. Mesh explantation is necessary in about 1-2% of patients due to complications. The initial approach appears to be an early surgical treatment with partial or complete mesh resection. Vaginal and endoscopic access for mesh resection is favored. Prior to recurrent surgeries, a careful examination and planning for the operation strategy are crucial. Conclusions. The data on the management of mesh complication is scarce. Revisions should be performed by an experienced surgeon and a proper follow-up with prospective documentation is essential for a good outcome.

Secondary surgery after vaginal prolapse repair with mesh is more common for stress incontinence and voiding dysfunction than for mesh problems or prolapse recurrence

OBJECTIVES

To explore the need for secondary surgical procedures after transvaginal prolapse repair with mesh.

METHODS

Women that had prolapse repair (Prolift(®) or Elevate(®)) were reviewed for reoperation and clinical/demographic data such as prior prolapse repair, prolapse grade, operative details, length of stay (LOS) and time to reoperation. Pearson's Chi-square, Fisher's exact tests and Wilcoxon rank tests were used.

RESULTS

77/335 women (23%) had 100 additional procedures. Median (range) time to reoperation was 51 (5-1168) days: four (1%) had primary prolapse surgery at a different site, three (1%) repeat prolapse repair from the same site, 23 (7%) surgery for complications and 50 (15%) had stress urinary incontinence (SUI)/sling-related procedures. When no reoperation versus reoperation groups were compared, mean LOS (1.8 vs. 2.0 days; p = 0.044) and follow-up (228 vs. 354 days; p = 0.002) were longer in the reoperations group; postoperative hemoglobin was lower (10.8 vs. 10.4; p = 0.031). Patients with a prolapse reoperation were 10 years younger (67 vs. 57 years; p = 0.027) than patients that either had a reoperation for other reasons or had no reoperations. Patients with concomitant sling and persistent SUI requiring repeat SUI surgery were older (mean 72 vs. 66 years; p = 0.038), had prior prolapse repair (53 vs. 27%; p = 0.017) and had anterior compartment mesh (84 vs. 56%; p = 0.037); median operative times (78 vs. 104 min; p = 0.008) and mean LOS were shorter (median 1.6 vs. 1.9 days; p = 0.045). For patients without concomitant sling, no demographic or perioperative differences were found between those that did (n = 10) and did not (n = 86) develop de novo SUI that required reoperation.

CONCLUSIONS

Most reoperations were for sling management and SUI; few were for mesh complications or prolapse recurrence.

Long-term follow-up of treatment for synthetic mesh complications

OBJECTIVES

The objectives of this study are (1) to describe the presenting symptoms, findings, and treatment and (2) to describe the self-reported improvement and function at least 6 months after presentation in women presenting to 1 urogynecology division for complications associated with synthetic vaginal mesh.

METHODS

Women evaluated between 2006 and 2011 were identified by diagnostic codes. We abstracted information from the medical record and attempted to contact all women to complete a follow-up telephone survey questionnaire consisting of several validated instruments.

RESULTS

A total of 111 women were evaluated for complications associated with synthetic vaginal mesh. The mean interval from index surgery was 2.4 years. Of these, 84% were referred from outside hospitals. Index surgeries included vaginal mesh kits/vaginally placed mesh (47%), midurethral mesh slings (37%), abdominally placed vaginal mesh (11%), and vaginal mesh kit with concomitantly placed mesh sling (5%). The most common complications were extrusion (65%), contraction (17%), and chronic pelvic pain (16%). A total of 98 women underwent some type of treatment (85 surgical) by urogynecologists, pelvic pain specialists, or physical therapists. Eighty-four (76%) provided follow-up information at mean interval since presentation of 2.3 years. At follow-up, the mean (SD) Pelvic Floor Distress Inventory score was 98 (67), the mean (SD) EQ-5D index score was 0.69 (0.23), and 22% reported vaginal discharge, 15% vaginal bleeding or spotting, and 45% sexual abstinence due to problems related to mesh. A total of 71% reported being overall better, whereas 29% were the same or worse.

CONCLUSIONS

Two years after tertiary care level multidisciplinary treatment of vaginal mesh complications, many women still report symptoms that negatively impact their quality of life.

Update in management of vaginal mesh erosion

Mesh erosion is one of the major complications of prolapse surgery conducted by transvaginal approach. Following the extensive use of meshes and warning about potential complications, a new classification of mesh-related adverse events has been proposed. Due to the wide scope of clinical features, no standardized approach has been proposed. Surgery is required after failure of conservative management, mostly based on mesh partial or total excision by transvaginal route, following the classic rules of re-do vaginal surgery. Complex cases are best managed in tertiary reference centers.

Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study

OBJECTIVE

The purpose of this study was to describe the evaluation and management of synthetic mesh-related complications after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP).

STUDY DESIGN

We conducted a multicenter, retrospective analysis of women who attended 4 US tertiary referral centers for evaluation of mesh-related complications after surgery for SUI and/or POP from January 2006 to December 2010. Demographic, clinical, and surgical data were abstracted from the medical record, and complications were classified according to the Expanded Accordion Severity Classification.

RESULTS

Three hundred forty-seven patients sought management of synthetic mesh-related complications over the study period. Index surgeries were performed for the following indications: SUI (sling only), 49.9%; POP (transvaginal mesh [TVM] or sacrocolpopexy only), 25.6%; and SUI + POP (sling + TVM or sacrocolpopexy), 24.2%. Median time to evaluation was 5.8 months (range, 0-65.2). Thirty percent of the patients had dyspareunia; 42.7% of the patients had mesh erosion; and 34.6% of the patients had pelvic pain. Seventy-seven percent of the patients had a grade 3 or 4 (severe) complication. Patients with TVM or sacrocolpopexy were more likely to have mesh erosion and vaginal symptoms compared with sling only. The median number of treatments for mesh complications was 2 (range, 1-9); 60% of the women required ≥2 interventions. Initial treatment intervention was surgical for 49% of subjects. Of those treatments that initially were managed nonsurgically, 59.3% went on to surgical intervention.

CONCLUSION

Most of the women who seek management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention; a significant proportion require >1 surgical procedure. The pattern of complaints differs by index procedure.