Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits

doi:10.1016/j.ajog.2008.07.055

American Journal of Obstetrics and Gynecology

Volume 199, Issue 6, December 2008, Pages 703.e1-703.e7

Presented at the 34th Annual Scientific Meeting of the Society of Gynecologic Surgeons, Savannah, GA, April 14-16, 2008.

https://doi.org/10.1016/j.ajog.2008.07.055 Get rights and content

Objective

The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit.

Study Design

This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms.

Results

Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms.

Conclusion

Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.

Section snippets

Materials and Methods

After institutional review board approval was obtained, the electronic medical records were reviewed for all patients who underwent surgical excision of transvaginal mesh from Jan. 1, 2005 to Dec. 31, 2007 at the Cleveland Clinic. Subjects were identified by searching a surgical database using International Classification of Diseases, Ninth Revision codes (57295, revision or removal of prosthetic vaginal graft [vaginal approach] and 57296, revision or removal of prosthetic vaginal graft

Results

Nineteen patients met inclusion criteria and were identified as having undergone mesh excision during the study period, as described in Table 1. The demographics are listed in Table 2. Mean age (± SD) was 59.6 (±10.9) years, the median parity was 3 (range, 1-7), and 84% had undergone previous hysterectomy. With the exception of 2 patients, transvaginal mesh was used for primary repair of pelvic organ prolapse (89%). All patients except for 2 had undergone either Anterior (9/19) or Total Prolift

Comment

Mesh kits have become popular for repair of prolapse but can result in long-term adverse outcomes sometimes requiring mesh removal. Indications for removal of vaginal mesh include chronic pain, dyspareunia, recurrent prolapse, and significant mesh erosion not amenable to conservative management. Excision of mesh to treat these complications is safe and often leads to significant improvement in symptoms.

Published studies report encouraging short-term anatomic outcomes following transvaginal mesh

References (10)

B.S. Yamada et al.
Vesicovaginal fistula and mesh erosion after Perigee (transobturator polypropylene mesh anterior repair)
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Surgical excision of eroded mesh after prior abdominal sacrocolpopexy
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Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair
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B. Fatton et al.
Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift trademark technique)—a case series multicentric study
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A. Gauruder-Burmester et al.
Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse
Int Urogynecol J Pelvic Floor Dysfunct
(2007)

There are more references available in the full text version of this article.

Cited by (76)

Pelvic and perineal pain after genital prolapse: A literature review
2020, Progres en Urologie
Les douleurs pelvi-périnéales postchirurgie du prolapsus génital sont des complications postopératoires graves et fréquentes dont le diagnostic et le traitement peuvent être complexes.
Nous avons réalisé une revue de la littérature sur la base de données Pubmed en utilisant les mots et MeSH suivants : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.
Parmi les 133 articles trouvés, 74 ont été retenus. Les douleurs pelvi-périnéales chroniques évoluent depuis plus de 3 mois selon l’International Association for the Study of Pain, et peuvent être de type nociceptif, neuropathique ou dysfonctionnel. Leur définition est avant tout clinique. Leur incidence varie de 1 à 50 % et les facteurs de risques suspectés sont un âge jeune, des comorbidités, un antécédent de chirurgie de prolapsus, un stade élevé de prolapsus, des douleurs préopératoires, une voie d’abord chirurgicale invasive, la pose simultanée de plusieurs prothèses, une moindre expérience de l’opérateur, une durée importante d’intervention et des douleurs postopératoires précoces. La voie vaginale peut favoriser une modification de la compliance ou de la longueur vaginale, des lésions des nerfs pudendaux, sciatiques ou obturateurs ou un syndrome myofascial pelviens ; la voie cœlioscopique est à risque de lésion des nerfs pariétaux ; la chirurgie prothétique implique des complications liées aux modifications de prothèse. La prise en charge thérapeutique est complexe et doit être multimodale et pluridisciplinaire.
Les connaissances sur les douleurs pelvi-périnéales après chirurgie du prolapsus génital sont encore limitées à ce jour.
Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.
A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.
Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.
Pelvic pain after genital prolapse surgery is still obscure to this day.
Safety and efficacy of spider anchoring device for apical repair in laparoscopic sacrocolpopexy: Retrospective cohort study
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Post-operative complication rate was low, including only chronic pain (2.3%) with no cases of mesh erosion in this cohort study. Mesh erosion after vaginal mesh surgery can reach up to 12% according to the literature [15–19]. The rate of mesh erosion after abdominal or laparoscopic SCP is lower during short follow-up, but can reach up to 10% in long-term (up to 3 years) follow-up [20–22].
The aim of the study was to assess safety and efficacy of apical support when using the soft-tissue metal fasteners of EndoFast Reliant™ SCP during laparoscopic sacrocolpopexy (LSCP).
This is a single-center, retrospective cohort study including all patients which underwent LSCP between 2015 and 2017. Safety outcome included the procedure and the device related complications. Effectiveness outcomes included the anatomical success of apical repair and the functional results as were obtained from the clinic and from a Quality of life questionnaire (PFDI-20).
Eighty-four patients, 54% with grade III and IV prolapse were included in the study. Uterus was preserved in 68% of patients with uterus. Mean follow-up period for the clinic visit was 4.5 ± 4 months. Short term anatomical success was achieved for 98.8% of the patients. Marked improvement was observed in the related symptoms including urinary incontinence. Three intra-operative complications occurred: 1 case of bladder injury, 1 case of intra-abdominal bleeding, and 1 case of post-operative vaginal bleeding. Later complications included only two patients (2.3%) complained of chronic abdominal pain. There were no cases of mesh erosion or de-novo dyspareunia. The mean follow-up period for the PFDI-20 questionnaire was 15.6 months. 75% of patients had no bulge symptoms at all. Quarter of the patients had some bulge symptoms, bothers them between somewhat to moderately according to the questionnaire grading.
The use of Endofast SCP fasteners for laparoscopic promonto-fixation is a safe and effective surgery. Longer follow-up and larger studies should be performed to establish the results.
Managing pain after synthetic mesh implants in pelvic surgery
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
Pelvic mesh surgery has courted controversy with around 10% of patients experiencing complications. This article concentrates on the factors around pain, its presentation and management. Immediate pain is related to insertion and immediate removal recommended. With later presentation excision of the mesh relieves pain in up to 80% of women. Infection may be contributory but in refractory cases other factors maybe involved. Idiosyncratic reaction to mesh without risk factors appears to be relatively rare.
Risk factors and management of vaginal mesh erosion after pelvic organ prolapse surgery
2017, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
Some studies have reported the experience of mesh erosion management [6,11,12]. In 2008, Ridgeway et al [11] reported their early experience of mesh revision in 19 patients. All these patients underwent surgical intervention with only a few reported complications related to the mesh removal and significant relief of symptoms.
Mesh erosion is a serious and not uncommon complication in women undergoing vaginal mesh repair. We hypothesized that mesh erosion is associated with the patient’s comorbidities, surgical procedures, and mesh material. The aims of this study were to identify the risk factors and optimal management for mesh erosion.
All women who underwent vaginal mesh repair from 2004 to 2014 were retrospectively reviewed. Data on patients’ characteristics, presenting symptoms, treatment and outcomes were collected from their medical records.
A total of 741 women underwent vaginal mesh repairs, of whom 47 had mesh erosion. The median follow-up period was 13 months (range 3–84 months). Another nine patients with mesh erosion were referred form other hospitals. Multivariate analysis revealed that concomitant hysterectomy (odds ratio 27.02, 95% confidence interval 12.35–58.82; p < 0.01) and hypertension (odds ratio 5.95, 95% confidence interval 2.43–14.49; p < 0.01) were independent risk factors for mesh erosion. Of these 56 women, 20 (36%) were successfully treated by conservative management, while 36 (64%) required subsequent surgical revision. Compared with surgery, conservative treatment was successful if the size of the erosion was smaller than 0.5 cm (p < 0.01). Six patients (17%) had recurrent erosions after primary revision, but all successfully healed after the second surgery.
Concomitant hysterectomy and hypertension were associated with mesh erosion. In the management of mesh erosion, conservative treatment can be tried as the first-line treatment for smaller erosions, while surgical repair for larger erosions. Recurrent erosions could happen and requires repairs several times.
Changes in pelvic organ prolapse mesh mechanical properties following implantation in rats
2016, American Journal of Obstetrics and Gynecology
Pelvic organ prolapse (POP) is a multifactorial disease that manifests as the herniation of the pelvic organs into the vagina. Surgical methods for prolapse repair involve the use of a synthetic polypropylene mesh. The use of this mesh has led to significantly higher anatomical success rates compared with native tissue repairs, and therefore, despite recent warnings by the Food and Drug Administration regarding the use of vaginal mesh, the number of POP mesh surgeries has increased over the last few years. However, mesh implantation is associated with higher postsurgery complications, including pain and erosion, with higher consecutive rates of reoperation when placed vaginally. Little is known on how the mechanical properties of the implanted mesh itself change in vivo. It is assumed that the mechanical properties of these meshes remain unchanged, with any differences in mechanical properties of the formed mesh-tissue complex attributed to the attached tissue alone. It is likely that any changes in mesh mechanical properties that do occur in vivo will have an impact on the biomechanical properties of the formed mesh-tissue complex.
The objective of the study was to assess changes in the multiaxial mechanical properties of synthetic clinical prolapse meshes implanted abdominally for up to 90 days, using a rat model. Another objective of the study was to assess the biomechanical properties of the formed mesh-tissue complex following implantation.
Three nondegradable polypropylene clinical synthetic mesh types for prolapse repair (Gynemesh PS, Polyform Lite, and Restorelle) and a partially degradable polypropylene/polyglecaprone mesh (UltraPro) were mechanically assessed before and after implantation (n = 5/ mesh type) in Sprague Dawley rats for 30 (Gynemesh PS, Polyform Lite, and Restorelle) and 90 (UltraPro and Polyform Lite) days. Stiffness and permanent extension following cyclic loading, and breaking load, of the preimplanted mesh types, explanted mesh-tissue complexes, and explanted meshes were assessed using a multi-axial (ball-burst) method.
The 4 clinical meshes varied from each other in weight, thickness, porosity, and pore size and showed significant differences in stiffness and breaking load before implantation. Following 30 days of implantation, the mechanical properties of some mesh types altered, with significant decreases in mesh stiffness and breaking load, and increased permanent extension. After 90 days these changes were more obvious, with significant decreases in stiffness and breaking load and increased permanent extension. Similar biomechanical properties of formed mesh-tissue complexes were observed for mesh types of different preimplant stiffness and structure after 90 days implantation.
This is the first study to report on intrinsic changes in the mechanical properties of implanted meshes and how these changes have an impact on the estimated tissue contribution of the formed mesh-tissue complex. Decreased mesh stiffness, strength, and increased permanent extension following 90 days of implantation increase the biomechanical contribution of the attached tissue of the formed mesh-tissue complex more than previously thought. This needs to be considered when using meshes for prolapse repair.
Short-term Outcomes of Non-robotic Single-incision Laparoscopic Sacrocolpopexy: A Surgical Technique
2020, Journal of Minimally Invasive Gynecology
Our main purpose was to describe the surgical technique and short-term outcomes of single-incision laparoscopic sacrocolpopexy (S-LSC) for the treatment of pelvic organ prolapse (POP).
This study consisted of a retrospective analysis of 49 consecutive cases.
This study was set at the Third Affiliated Hospital of Guangzhou Medical University from October 2016 to November 2017.
The population for this study consisted of women with stage II to IV POP who met eligibility criteria for laparoscopic surgery.
S-LSC included the use of V-loc barbed suture and retroperitoneal tunneling, in addition to standard single-incision laparoscopic surgery techniques. All 49 cases were successfully completed. All cases included concomitant procedures; 42 (85.7%) had removal of the uterus and adnexa. The main measured outcomes include patient characteristics, perioperative outcomes, and change in pelvic floor support (Pelvic Organ Prolapse Quantification System), and quality of life (Pelvic Floor Impact Questionnaire).
All patients were parous, and 42.9% had a history of previous abdominal surgery. The mean operative duration from skin to skin was 201.20 ± 46.53 minutes. The mean estimated blood loss was 27.0 ± 16.6 mL. The mean pre- and post-operative Pelvic Organ Prolapse Quantification System scores were 2.2 ± 1.1 cm versus −2.6 ± 0.5 cm for the Aa point and 3.2 ± 2.8 cm versus −4.6 ± 0.8 cm for the C point (p <.05 for both). The mean pre- and post-operative Pelvic Floor Impact Questionnaire scores were 106.4 ± 18.9 versus 8.9 ± 4.26 (p <.05), suggesting that S-LSC significantly improved physical prolapse and quality of life. Four patients suffered from postoperative complications (3 mesh exposure and 1 lumbosacral pain). Six patients complained of new onset of stress urinary incontinence.
Single-incision laparoscopic sacrocolpopexy is a feasible method to manage POP. However, the long-term effects and complications need to be further investigated.

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: Cite this article as: Ridgeway B, Walters MD, Paraiso MFR, et al. Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits. Am J Obstet Gynecol 2008;199:703.e1-703.e7.

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Meeting paperSGS paperEarly experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Urology

Am J Obstet Gynecol

Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair

Obstet Gynecol

Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift trademark technique)—a case series multicentric study

Int Urogynecol J Pelvic Floor Dysfunct

Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse

Int Urogynecol J Pelvic Floor Dysfunct

Meeting paper
SGS paper
Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits