Risk factors for mesh erosion after vaginal sling procedures for urinary incontinence

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Abstract

Objectives

To identify risk factors for mesh erosion in women undergoing vaginal sling procedures for urinary incontinence with synthetic meshes, and to estimate the incidence of mesh erosion after these procedures.

Study design

Retrospective study of women who underwent vaginal sling procedures between January 2007 and January 2013. In total, 1439 consecutive women with stress urinary incontinence were investigated. Five hundred and sixty-six (39.3%) women underwent a tension-free vaginal tape (TVT) procedure and 873 (60.7%) women underwent a transobturator tape (TOT) procedure. All procedures were performed using meshes of the same type and size. Women who experienced mesh erosion were defined as cases, and women who were not re-admitted or identified with mesh erosion during the study period were defined as controls. Demographics, operative techniques and outcomes were taken from medical records. Multivariate regression identified the odds of mesh erosion.

Results

Sixty-one of 1439 (4.2%) women were found to have mesh erosion in the postoperative period: 41 (67.2%) after TOT procedures and 20 (32.8%) after TVT procedures. The rate of mesh erosion was 4.7% in the TOT group and 3.5% in the TVT group, and this difference was significant (p < 0.05). Mean age, body mass index, current smoking, menopausal status and diabetes mellitus were significantly higher among cases than controls. Univariate analysis showed that length of vaginal incision >2 cm, recurrent vaginal incision for postoperative complications, and previous pelvic organ prolapse or incontinence surgery were significant risk factors for erosion. Multivariate analysis demonstrated that older age, diabetes mellitus, current smoking, length of vaginal incision >2 cm, recurrent vaginal incision for postoperative complications, and previous pelvic organ prolapse or incontinence surgery were independent risk factors for mesh erosion.

Conclusions

Mesh erosion following vaginal sling procedures is a frustrating complication with relatively low incidence. It was found to occur more often after TOT procedures than TVT procedures. Older age, diabetes mellitus, smoking, length of vaginal incision >2 cm, recurrent vaginal incision for postoperative complications, and previous vaginal surgery for pelvic organ prolapse or incontinence increased the risk of mesh erosion. Identification of risk factors may enable surgeons to prevent or minimize this complication.

Introduction

Stress urinary incontinence (SUI) is the most common type of urinary incontinence and is generally treated surgically [1], [2]. Vaginal sling procedures have become the standard technique for the surgical treatment of SUI, in which synthetic mesh material is located suburethrally under the vaginal mucosa. The tension-free vaginal tape (TVT) procedure, developed by Ulmsten et al. in 1996, was one of the first retropubic midurethral sling procedures [3], [4]. During this procedure, approaching the posterior pubic cavity may cause bladder perforation and vessel, nerve or bowel injuries. As such, the transobturator tape (TOT) procedure was developed more recently to minimize associated morbidity [5]. Studies have demonstrated that these procedures are very effective and have similar cure rates for SUI [6], [7]. However, using synthetic tape material may have complications such as rejection, infection and erosion [8]. Hence, concerns about mesh complications have made these procedures controversial.

A literature review undertaken by the US Food and Drug Administration found that mesh erosion through the vagina is one of the most common complications following transvaginal procedures that use meshes. Several factors contribute to the wide range of vaginal erosion rates, including patient characteristics (e.g. age and oestrogen deficiency), operative technique, implant size and specific properties of the graft material (e.g. pore size, stiffness, elasticity and basic tissue compatibility) [9]. This study aimed to identify the risk factors for mesh erosion in women undergoing vaginal sling procedures for SUI with synthetic meshes, and to determine the incidence of mesh erosion after these procedures.

Section snippets

Materials and methods

This retrospective study consisted of 1439 women who had undergone vaginal sling procedures for SUI at the Department of Obstetrics and Gynaecology, Zekai Tahir Burak Woman's Health Education and Research Hospital, Ankara, Turkey, from January 2007 to January 2013. Ethical approval was obtained from the regional hospital ethics committee. Five hundred and sixty-six women underwent TVT procedures and 873 women underwent TOT procedures. All procedures were performed using meshes of the same type

Results

During the study period, 1439 vaginal sling procedures for SUI were performed. Postoperative mesh erosion occurred in 61 patients (4.2%): 41 (67.2%) TOT and 20 (32.8%) TVT procedures. All mesh erosions were located in the midline.

The characteristics of the case and control groups are shown in Table 1. The mean ± standard deviation age of cases was significantly higher than that of controls (50.57 ± 8.33 vs 46.69 ± 7.34, respectively). Mean body mass index (BMI) was significantly lower in controls

Comment

Over the last decade, suburethral sling procedures, using synthetic meshes, have gradually become the primary surgical management for SUI in females. Their popularity is related to the avoidance of a secondary harvesting site, decreased surgical time and similar efficacy in comparison with autologous slings [11]. However, the increasing use of synthetic material has given rise to a wide variety of complications such as mesh erosion, infection, retraction and pelvic pain [12]. The incidence of

Funding

None declared.

Condensation

Awareness of the risk factors associated with mesh erosion following midurethral sling procedures may help surgeons to minimize the complication rate.

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