Complications from vaginally placed mesh in pelvic reconstructive surgery

The double-edged sword of mesh use in pelvic organ prolapse surgery: a case report

Introduction

Pelvic organ prolapse (POP) is a prevalent condition among parous women, often warranting surgical intervention. This case accentuates the complications associated with mesh in POP surgeries, iterating the imperative need for an evidence-based approach towards its utilization and exhaustive patient counselling.

Case presentation

A 60-year-old female, post-mesh-augmented POP repair, embarked on a 13-year journey characterized by persistent pelvic pain and multiple interventions. Despite undergoing several surgeries across different countries, involving mesh and stone removals, her symptoms, notably pelvic pain and dyspareunia, persisted. Clinical examinations revealed mesh erosion into the perivesical tissue, bladder, and associated stones, which were addressed through multiple interventions, albeit with transient success.

Discussion

The complex journey of this patient exemplifies the intricate challenges mesh poses in POP surgeries. While mesh application offers a minimally invasive approach and has proven successful in numerous cases, it simultaneously opens a Pandora's box of potential severe complications, necessitating thorough patient counselling and post-surgery management.

Conclusion

The case delineates the challenging path that clinicians and patients tread when navigating through mesh-associated complications post-POP repair. Although mesh has been heralded as a revolutionary approach in POP surgeries, its potential drawbacks necessitate judicious application, ensuring clinicians are well-versed with its associated risks and are adept in managing ensuing complications.

3D printing in vaginal drug delivery: a revolution in pharmaceutical manufacturing

INTRODUCTION

The Food and Drug Administration's approval of the first three-dimensional (3D) printed tablet, Spritam®, led to a burgeoning interest in using 3D printing to fabricate numerous drug delivery systems for different routes of administration. The high degree of manufacturing flexibility achieved through 3D printing facilitates the preparation of dosage forms with many actives with complex and tailored release profiles that can address individual patient needs.

AREAS COVERED

This comprehensive review provides an in-depth look into the several 3D printing technologies currently utilized in pharmaceutical research. Additionally, the review delves into vaginal anatomy and physiology, 3D-printed drug delivery systems for vaginal applications, the latest research studies, and the challenges of 3D printing technology and future possibilities.

EXPERT OPINION

3D printing technology can produce drug-delivery devices or implants optimized for vaginal applications, including vaginal rings, intra-vaginal inserts, or biodegradable microdevices loaded with drugs, all custom-tailored to deliver specific medications with controlled release profiles. However, though the potential of 3D printing in vaginal drug delivery is promising, there are still challenges and regulatory hurdles to overcome before these technologies can be widely adopted and approved for clinical use. Extensive research and testing are necessary to ensure safety, effectiveness, and biocompatibility.

Short term complications in mesh augmented vaginal repair of pelvic organ prolapse are not higher when compared with native tissue repair

INTRODUCTION AND HYPOTHESIS

Accumulating evidence regarding the negative long-term consequences of transvaginal mesh-based procedures for pelvic organ prolapse has led to a sharp decline in mesh-based procedures. We aimed to evaluate the short-term complications of mesh-based procedures for carefully selected patients with pelvic organ prolapse after Food and Drug Administration warnings.

METHODS

A retrospective database review of the ACS NSQIP database was completed to examine 30-day complications including re-operation, prolonged length of stay, blood transfusion, surgical site infection, urinary tract infection, readmission and wound dehiscence in mesh-augmented and native tissue-based transvaginal procedures for pelvic organ prolapse.

RESULTS

A total of 36,234 patients were included in the analysis, with only 7.1% (2574 women) having mesh-augmented repair. Using a multivariable logistical regression analysis adjusting for confounders, we found that the primary composite outcome (re-operation, hospital stay, blood transfusion and surgical site infection) was less common in the mesh group compared with the native tissue repair group (adjusted OR 0.80, CI 0.67-0.95, p = 0.009). The secondary outcomes (urinary tract infection, re-admission and wound dehiscence) were not different between the group.

CONCLUSION

These results suggest that in well-chosen patients, short-term complications are not increased when using transvaginal mesh for pelvic organ prolapse repair.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

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.

RESULTS

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.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Endoscopic lithotripsy and vaginal excision of a calcified bladder-mesh extrusion

INTRODUCTION AND HYPOTHESIS

Synthetic meshes have proven to increase efficacy of pelvic organ prolapse (POP) repair, but associated complications are not rare. Bladder mesh extrusion is one of the most serious adverse events following POP surgery with mesh. The aim of this video was to describe endoscopic and vaginal approaches for treating a bladder-mesh extrusion.

METHODS

A 52-year-old female patient with a history of vaginal POP surgery with mesh was referred for severe pelvic and perineal pain, dyspareunia, and dysuria. She was found to have a bladder calculus on a mesh extrusion. The calculus was removed by endoscopic lithotripsy before vaginal mesh excision was performed.

CONCLUSIONS

With the use of synthetic vaginal mesh, the incidence of bladder-mesh extrusion could increase. This didactic video will be helpful to surgeons required to manage such cases using a minimally invasive treatment.

3-year results of transvaginal cystocele repair with transobturator four-arm mesh: A prospective study of 105 patients

OBJECTIVES

To evaluate the long-term efficacy and safety of transobturator four-arm mesh for treating cystoceles.

PATIENTS AND METHODS

In this prospective study, 105 patients had a cystocele corrected between January 2004 and December 2008. All patients had a symptomatic cystocele of stage ⩾2 according to the Baden-Walker halfway stratification. We used only the transobturator four-arm mesh kit (Surgimesh®, Aspide Medical, France). All surgical procedures were carried out by the same experienced surgeon. The patients' characteristics and surgical variables were recorded prospectively. The anatomical outcome, as measured by a physical examination and postoperative stratification of prolapse, and functional outcome, as assessed by a questionnaire derived from the French equivalents of the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and the Pelvic Organ Prolapse-Urinary Incontinence-Sexual Questionnaire, were considered as the primary outcome measures. Peri- and postoperative complications constituted the secondary outcome measures.

RESULTS

At 36 months after surgery the anatomical success rate (stage 0 or 1) was 93%. On a functional level, all the scores of quality of life and sexuality were improved. The overall satisfaction score (visual analogue scale) was 71.4%. There were no perioperative adverse events. Mesh erosion was reported in 7.6% and mesh retraction in 5.7% of the patients.

CONCLUSIONS

If the guidelines and precautions are followed, vaginal prosthetic surgery for genitourinary prolapse has shown long-term benefits. It provides excellent results both anatomically and functionally. However, complications are not negligible and some are specific to prosthetic surgery.

Referral patterns for pelvic floor surgical prosthesis complications: from symptom onset and initial treatments to evaluation at a tertiary care center

Although complications of prosthesis products used for pelvic organ prolapse and stress urinary incontinence have been extensively characterized, little is known about their referral patterns and the time lapse from symptom onset to evaluation and treatment. The aim of our study was to retrospectively describe the patterns and timing of referral of prosthesis-related complications and initial prereferral treatments.

METHODS

We retrospectively identified patients referred to the University of Virginia from January 2002 to October 2012 with prosthesis complications related to previously placed devices for pelvic floor disorders.

RESULTS

We identified 55 prosthesis-related complications in 51 patients. The types of prostheses used included mesh or permanent suture for pelvic organ prolapse (vaginal prolapse, n = 24), tapes for stress urinary incontinence (midurethral, n = 21), and materials for abdominal sacrocolpopexies and vaginal vault suspensions (intraperitoneal, n = 10). Original surgeons, who most frequently were general obstetric/gynecology providers, were the referring physicians for only 3.6% of the time. Vaginal and midurethral prosthesis complications occurred most commonly in the early postoperative period, whereas intraperitoneal were more commonly delayed. Patients reported to have experienced adverse symptoms on average from several months up to years while receiving conservative therapies by secondary providers and/or surgical treatments with their original surgeon before referral to our institution.

CONCLUSIONS

Referral of prosthesis-related complications is often delayed, and most cases required evaluation by a secondary provider other than the original surgeon before a referral was initiated. Timing of symptom onset was dependent on the prosthesis type with up to 1 in 3 having a late presentation that may in part be delayed by prereferral treatments. Further education of original surgeons, primary care providers, and patients on the presentation, timing, and outcomes of potential prosthesis-related complications is needed to facilitate earlier management at tertiary care centers.

Early results of a novel technique for anterior vaginal wall prolapse repair: anterior vaginal wall darn

BACKGROUND

The aim of this study was to describe the results of a 1-year patient follow-up after anterior vaginal wall darn, a novel technique for the repair of anterior vaginal wall prolapse.

METHODS

Fifty-five patients with anterior vaginal wall prolapse underwent anterior vaginal wall darn. The anterior vaginal wall was detached using sharp and blunt dissection via an incision beginning 1 cm proximal to the external meatus and extending to the vaginal apex. The space between the tissues that attach the lateral vaginal walls to the arcus tendineus fasciae pelvis was then darned. Cough Stress Test, Pelvic Organ Prolapse Quantification, seven-item Incontinence Impact Questionnaire, and six-item Urogenital Distress Inventory scores were performed 1-year postoperatively to evaluate recovery.

RESULTS

One-year postoperatively, all patients were satisfied with the results of the procedure. No patient had vaginal mucosal erosion or any other complication.

CONCLUSIONS

One-year postoperative findings for patients in this series indicate that patients with stage II-III anterior vaginal wall prolapse were successfully treated with the anterior vaginal wall darn technique.

Pectineal ligament suspension of prolapsed vaginal vault

OBJECTIVE

To report on a collective pectineal ligament suspension experience acquired over 12 years in India with 119 women who presented with prolapsed vaginal vault. The feasibility and effectiveness of the procedure was assessed for the open and laparoscopic routes.

METHODS

The prolapsed vaginal vault was suspended unilaterally to the pectineal ligament using polyester tape at 3 urban and 3 rural hospitals. The procedure was done through a Cherney incision in 104 women. In the remaining 15 women, it was done laparoscopically at a single urban center.

RESULTS

There were no intraoperative complications. The mean follow-up was 5.5 years (range, 0.5-12 years). Only 2 women had vaginal prolapse recurrence, at 3 and 5 years. Two had asymptomatic tape erosion, at 2 and 5 years, and a mild cystocele appeared in 5 women and a low rectocele in 4. However, none of these women required further vaginal surgery during their follow-up period.

CONCLUSION

The present study demonstrates the long-term safety and effectiveness of pectineal ligament suspension for vaginal vault prolapse by the open and the laparoscopic routes. As it was done by surgeons of varying experience at centers with varying resources, the procedure can be readily mastered by any gynecologic surgeon.

A novel technique for anterior vaginal wall prolapse repair: anterior vaginal wall darn

AIM

The aim of this study is to introduce a new technique, anterior vaginal wall darn (AVWD), which has not been used before to repair the anterior vaginal wall prolapse, a common problem among women.

MATERIALS AND METHODS

Forty-five women suffering from anterior vaginal wall prolapse were operated on with a new technique. The anterior vaginal wall was detached by sharp and blunt dissection via an incision beginning from the 1 cm proximal aspect of the external meatus extending to the vaginal apex, and the space between the tissues that attach the lateral walls of the vagina to the arcus tendineus fascia pelvis (ATFP) was then darned. Preoperation and early postoperation evaluations of the patients were conducted and summarized.

RESULTS

Data were collected six months after operation. Cough stress test (CST), Pelvic Organ Prolapse Quantification (POP-Q) evaluation, Incontinence Impact Questionnaire (IIQ-7), and Urogenital Distress Inventory (UDI-6) scores indicated recovery. According to the early postoperation results, all patients were satisfied with the operation. No vaginal mucosal erosion or any other complications were detected.

CONCLUSION

In this initial series, our short-term results suggested that patients with grade II-III anterior vaginal wall prolapsus might be treated successfully with the AVWD method.

Ureteral injury during vaginal mesh excision: role of prevention and treatment options

Vaginal mesh kits are increasingly used in vaginal prolapse repair. Mesh erosion, infection, and pain may necessitate removal, which can lead to urinary tract injury. We describe 2 cases of ureteral injury at the time of mesh excision. Surgeons must recognize the possibility of ureteral injury and treatment modalities available.

Tissue engineering as a potential alternative or adjunct to surgical reconstruction in treating pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Cell-based tissue engineering strategies could potentially provide attractive alternatives to surgical reconstruction of native tissue or the use of surgical implants in treating pelvic organ prolapse (POP).

METHODS

Based on a search in PubMed, this review focuses on candidate cell types, scaffolds, and trophic factors used in studies examining cell-based tissue engineering strategies to treat POP, stress urinary incontinence (SUI), and the closely related field of hernias.

RESULTS

In contrast to the field of SUI, the use of cell-based tissue engineering strategies to treat POP are very sparsely explored, and only preclinical studies exist.

CONCLUSION

The available evidence suggests that the use of autologous muscle-derived cells, fibroblasts, or mesenchymal stem cells seeded on biocompatible, degradable, and potentially growth-promoting scaffolds could be an alternative to surgical reconstruction of native tissue or the use of conventional implants in treating POP. However, the vagina is a complex organ with great demands of functionality, and the perfect match of scaffold, cell, and trophic factor has yet to be found and tested in preclinical studies. Important issues such as safety and economy must also be addressed before this approach is ready for clinical studies.

Tissue engineering as a potential alternative or adjunct to surgical reconstruction in treating pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Cell-based tissue engineering strategies could potentially provide attractive alternatives to surgical reconstruction of native tissue or the use of surgical implants in treating pelvic organ prolapse (POP).

METHODS

Based on a search in PubMed, this review focuses on candidate cell types, scaffolds, and trophic factors used in studies examining cell-based tissue engineering strategies to treat POP, stress urinary incontinence (SUI), and the closely related field of hernias.

RESULTS

In contrast to the field of SUI, the use of cell-based tissue engineering strategies to treat POP are very sparsely explored, and only preclinical studies exist.

CONCLUSION

The available evidence suggests that the use of autologous muscle-derived cells, fibroblasts, or mesenchymal stem cells seeded on biocompatible, degradable, and potentially growth-promoting scaffolds could be an alternative to surgical reconstruction of native tissue or the use of conventional implants in treating POP. However, the vagina is a complex organ with great demands of functionality, and the perfect match of scaffold, cell, and trophic factor has yet to be found and tested in preclinical studies. Important issues such as safety and economy must also be addressed before this approach is ready for clinical studies.

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.

Medium-term clinical outcomes following surgical repair for vaginal prolapse with tension-free mesh and vaginal support device

INTRODUCTION AND HYPOTHESIS

This study was designed to evaluate clinical outcomes ≥2 years following surgery with polypropylene mesh and vaginal support device (VSD) in women with vaginal prolapse, in a prospective, multi-center setting.

METHODS

Patients re-consented for this extended follow-up (n = 110), with anatomic evaluation using Pelvic Organ Prolapse Quantification (POP-Q) and validated questionnaires to assess pelvic symptoms and sexual function. Complications were recorded (safety set; n = 121).

RESULTS

Median length of follow-up was 29 months (range 24-34 months). The primary anatomic success, defined as POP-Q 0-I, was 69.1%; however, in 84.5% of the cases, the leading vaginal edge was above the hymen. Pelvic symptoms and sexual function improved significantly from baseline (p < 0.01). Mesh exposure rate was 9.1%. Five percent reported stress urinary incontinence and 3.3% required further prolapse surgery.

CONCLUSION

These results indicate this non-anchored mesh repair is a safe and effective treatment for women with symptomatic vaginal prolapse in the medium term.

Internal pudendal artery injury during prolapse surgery using nonanchored mesh

Herein is presented the case of a patient with stage 2 uterine prolapse treated surgically using nonanchored mesh. Complications were internal pudendal artery injury and a massive presacral hematoma that formed after surgery. Transcatheter arterial embolization was performed immediately, and the bleeding stopped. The patient subsequently experienced difficulty micturating and defecating because of presacral hematoma compression. Self-micturation and defecation capabilities were regained gradually at approximately 1 week after surgery. The hematoma resolved completely by 71 days postoperatively. Comprehensive knowledge of pelvic anatomy is important when performing surgery to treat prolapse using mesh kits. Removing the mesh and prophylactic antibiotic therapy is a means of conservatively managing a pelvic hematoma caused by prolapse surgery.

Rectal obstruction after a vaginal posterior compartment polypropylene mesh fixed to the sacrospinous ligaments

We present a case in which a polypropylene mesh was placed over the posterior vaginal wall and was fixed to the sacrospinous ligaments on both sides. Postoperative a rectal obstruction developed which was only resolved after splitting the entire mesh in the midline. It is hypothesised that the obstruction was due to the fixation of the mesh with irresolvable suture material to the sacrospinous ligaments acting as a hinge on which the bowel folded.

Tissue response to a new type of biomaterial implanted subcutaneously in rats

INTRODUCTION AND HYPOTHESIS

A new type of resorbable biomaterial intended for pelvic reconstruction was tested with respect to tissue regeneration and biocompatibility in rats. The biomaterial consisted of methoxypolyethyleneglycol-poly(lactic-co-glycolic acid) (MPEG-PLGA). Implants were pure, enriched with extra-cellular matrix (ECM) or estrogen.

METHODS

Ten implants of each type were tested for 3 and 8 weeks, respectively. Histological assessment of connective tissue organization, inflammation, vascularization, and thickness of regenerated tissue was undertaken.

RESULTS

All implants had a high degree of biocompatibility. ECM-enriched implants had significantly higher inflammatory scores compared to pure implants at 3 weeks. At 8 weeks, neither of the parameters differed significantly. No trace of the implants remained.

CONCLUSIONS

The MPEG-PLGA is highly biocompatible, degrades quickly, and seems inert in the process of tissue regeneration. Thus, it is hardly a candidate per se in reinforcement of pelvic reconstruction, but it could have a future role as carrier for stem cells.

Transrectal mesh erosion remote from sacrocolpopexy: management and comment

Sacrocolpopexy is an effective treatment for advanced pelvic organ prolapse with predictable anatomic and functional outcomes. We describe a rare complication of mesh erosion into the rectum and subsequent multidisciplinary management. Multidisciplinary, experienced subspecialty care can address difficult complications of pelvic floor surgery with a minimally invasive approach.

Can sex survive pelvic floor surgery?

INTRODUCTION/HYPOTHESIS

Sexual function in women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) is adversely affected, but data reporting sexual function following surgery are limited. We aimed to determine effect of pelvic reconstructive surgery on sexual function and to evaluate effect of additional continence procedures.

METHODS

Women with POP or SUI were assessed using pelvic organ prolapse quantification (POP-Q) or videocystourethrography. Sexual function was assessed with Golombok Rust Inventory of Sexual Satisfaction (GRISS) and sexual domains on prolapse quality of life (P-QoL) questionnaire and King's Health questionnaire. Women were reviewed over 2 years using all these objective and subjective assessments.

RESULTS

In total, 52 patients were followed up over 2 years. Sexual function measured using GRISS scores and sexual function domain scores of KHQ and P-QoL improved following surgery. A better supported pelvic floor (POP-Q) was associated with significantly improved GRISS scores.

CONCLUSIONS

These findings aid in pre-operative counselling of women with POP and SUI about potential improvement in sexual function post-operatively.