Short-term surgical outcomes and characteristics of patients with mesh complications from pelvic organ prolapse and stress urinary incontinence surgery. Int Urogynecol J. 2014;25:465-470. [PMID: 24085144 DOI: 10.1007/s00192-013-2227-3]

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

Objective

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

Materials and methods

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

Results

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

Conclusion

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

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.

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.

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery

PURPOSE OF REVIEW

To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery.

RECENT FINDINGS

Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

T regulatory cells and TGF-β1: Predictors of the host response in mesh complications

Polypropylene mesh is frequently used in urogynecology procedures; however, pain and mesh exposure into the vagina occur in ~10% of cases. Mesh-induced pain, which occurs with or without exposure, persists after removal in 50% of cases. Chronic pain history predicts poor response to mesh removal but only a fraction have this diagnosis. We hypothesize that mesh induced pain is correlated with fibrosis and failure to improve with a heightened inflammatory and fibrotic host response. Women undergoing mesh removal were offered participation in a mesh biorepository. Standardized questionnaires including visual analog scale (VAS) pelvic pain scores were completed at enrollment and 6 months after removal. Responders were considered those with ≥13 mm VAS improvement. 30 mesh-tissue explants were randomly selected for analysis. Samples were labeled for CD8, CD4 (T_h) and FoxP3 (T_regs). Peri-fiber collagen deposition (fibrosis) was measured using a customized semi-quantitative assay. Concentrations of TGF-b1, bFGF, MCP-1, PDGF-BB, and IGFBP-1 in tissue were determined by immunoassay and compared to vaginal control biopsies with pathway analysis. VAS pain scores were correlated with degree of histologic fibrosis. Responders had more T_regs (7.8 vs 0.3 per mm², p = 0.036) and patients were 1.6 times as likely to be a responder for every additional T_reg/mm² (p = 0.05). Pro-fibrotic TGF-β1 was doubled in nonresponders (p = 0.032). On pathway analysis, decreased bFGF and increased PDGF-BB provide a possible mechanism for upregulation of TGF-β1. In conclusion, fibrosis is a plausible mechanism of pain complications and the adaptive immune response likely contributes to mitigation/prevention of complications and recovery in affected patients. STATEMENT OF SIGNIFICANCE: Polypropylene mesh improves anatomical outcomes in urogynecologic procedures, but is associated with complications, including pain and exposure through the vaginal epithelium. Mesh-induced pain is difficult to treat, and it is unclear why only half of women experience pain improvement after mesh removal. In this study, patient pain correlated with the presence of fibrosis and women with more T regulatory cells and lower TGF-β1 were more likely to have pain improvement following mesh removal. These findings implicate fibrosis as a mechanism of pain complications and suggest that the adaptive immune response may be responsible for prevention of complication and recovery. This improved understanding of how mesh can lead to pain moves us closer to the ultimate goal of preventing mesh complications.

Complications and re-operations after tension-free vaginal tape operation in women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

We evaluate intraoperative and short-term postoperative (≤ 3 months) complications and long-term re-operations (up to 6 years) after tension-free vaginal tape (TVT) operation in women with stress urinary incontinence (SUI).

METHODS

Data from 446 women undergoing TVT operation between 2012 and 2016 at a tertiary referral center was retrospectively collected. Data included patient baseline demographics, information from the TVT operation and the following postoperative period, and scores from patient questionnaires [the International Consultation of Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and Patient Global Impression of Improvement (PGI-I)]. Collected data were investigated for incidence of complications and re-operations, postoperative improvement in patient questionnaires, and association between complications and baseline patient demographics.

RESULTS

The only intraoperative complication was bladder perforation (2.0%). Postoperative complications included: infection (0.7%), hematoma (0.9%), bleeding (0.2%), pain (0.9%), erosion of the vaginal mucosa (1.1%), persistent SUI (0.7%), and voiding dysfunction > 24 h (10.3%). Re-operations included: operation due to infections (0.4%), incontinence surgery for persistent SUI (0.4%), revision for tape erosion (1.1%), tape mobilization (3.6%), and tape division (0.2%). A significant reduction in urinary incontinence symptoms was observed in the ICIQ-UI SF and PGI-I. The reduction in ICIQ-UI SF did not vary significantly between patients with and without complications. No association between complications and baseline patient demographics was found.

CONCLUSION

This study demonstrated high safety and efficacy of the TVT operation with only minor short-term complications and few long-term re-operations. The ICIQ-UI SF improved significantly postoperatively and was not statistically significantly affected by the occurrence of complications.

The International Urogynecological Association/International Continence Society classification of complications of prosthesis and graft insertion: Pros and cons and a review of the literature

International Urogynecological Association (IUGA) and the International Continence Society (ICS) and the Joint IUGA/ICS Working Group on Complications Terminology formulated a standardized terminology and classification of complications related to the use of prosthesis in female pelvic floor surgeries. It was mainly purposed to globally standardize the complications and related definitions in order to obtain factual rates and to enable comparisons and surgical audits. Although this unique classification has frequently been cited in the literature, some concerns have been raised against its complexity of use and inter- and intraobserver variability. This review aimed to discuss the rationale behind the IUGA/ICS complication classification system, underline the opposing views, and provide the Turkish version of an online calculator facilitating the universal coding to increase the utility.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Persistent Postoperative Pain: Pathophysiology, Risk Factors, and Prevention

OBJECTIVE

Persistent postoperative pain (PPOP) is the second most common reason for a patient to seek care at a chronic pain center. Many of the patients seen with prolapse or incontinence are at risk for developing PPOP as a result of the surgeries done for these problems. The pathophysiology of this disabling pain disorder is well understood, and the risk factors are easy to identify. Once identified, perioperative interventions can be offered to attempt to prevent PPOP.

METHODS AND RESULTS

Evaluation of articles obtained using a MEDLINE search involving chronic pain and PPOP, including prevalence, pathophysiology, and prevention was reviewed. The concept of central censitization and the key role it plays in chronic pain disorders were also reviewed. A history of chronic pain (anywhere) as well as findings of levator myalgia, allodynia, and hypertonic pelvic floor disorders is critical in identifying patients at risk for PPOP.

CONCLUSIONS

Identification of patients at risk allows the clinician to educate the patient about the risk of PPOP and the various perioperative interventions that can be used to prevent its development. Further studies will be required to determine how effective these interventions are in patients undergoing surgery for incontinence and/or pelvic organ prolapse.

Iatrogenic Pelvic Pain: Surgical and Mesh Complications

Female stress urinary incontinence and pelvic organ prolapse are prevalent conditions in adult women. Among treatment alternatives, more traditional methods of surgical intervention have been supplanted by synthetic polypropylene mesh kits. However, novel complications with mesh-related exposure, pelvic pain alone or with dyspareunia, and increased incidence of revision surgeries, resulted in 2 FDA warnings on transvaginal mesh use for prolapse repair. This review examines the anatomy of the vagina and urethra, the etiology of pain related to mesh use, and the relevant surgical techniques for management of this complication along with their outcomes.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System

PURPOSE

We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery.

MATERIALS AND METHODS

With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed.

RESULTS

Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications.

CONCLUSIONS

Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Sacrospinous ligament suspension with transobturator mesh versus sacral colpopexy for genital prolapse

OBJECTIVE

To compare the safety and efficacy of abdominal sacral colpopexy and sacrospinous ligament suspension with the use of vaginal mesh for apical prolapse.

METHOD

This retrospective study was conducted from 2005 to 2012 and included 89 women with apical prolapse who underwent surgery. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. Rates of objective cure and immediate/late complications were compared.

RESULTS

In total, 41 of the 89 women underwent sacrospinous ligament suspension, and 48 of the women underwent abdominal sacral colpopexy. A total of 40.4% of the women had vault prolapse (p=0.9361). Most of them had no complications (93.2%) (p=0.9418). Approximately 30% of the women had late complications; local pain was the main symptom and was found only in women who underwent the abdominal procedure (25.6%) (p=0.001). Only the women who were submitted to the vaginal procedure had mesh exposure (18.4%). The objective success rate and the rate of anterior vaginal prolapse (p=0.2970) were similar for both techniques.

CONCLUSION

Sacrospinous ligament suspension was as effective and had a similar objective success rate as abdominal sacral colpopexy for the treatment of apical prolapse. Sacrospinous ligament suspension performed with the use of vaginal mesh in the anterior compartment was effective in preventing anterior vaginal prolapse after surgery.

Assessing the use of the IUGA/ICS classification system for prosthesis/graft complications in publications from 2011 to 2015

INTRODUCTION AND HYPOTHESIS

Complications of pelvic organ prolapse and urinary incontinence surgery have gained increasing attention from both lay media and medical societies. The International Urogynecological Association and International Continence Society proposed the category-time-site system to classify complications in 2011. Our objective is to assess the usage of the category-time-site system in the literature.

METHODS

We conducted a systematic review and identified records using PubMed search terms "mesh" and "prolapse or incontinence" and "complication or excision" (February 2011 to December 2015) to select publications following the introduction of category-time-site system. Relevant publications were included and reviewed for study design, initial procedure, number of patients assigned codes, number of unique codes applied, purpose of assigning codes, and duration of clinical follow-up.

RESULTS

Of 167 eligible records, 23 (14 %) used the system, 137 (82 %) used no system, and 7 (4 %) used another system. They included three study designs: randomized control trials, case reports, and case series. Given the very limited amount of data, no statistical tests were performed, but trends were noted.

CONCLUSIONS

Fourteen percent of the reports in the literature describing complications related to prosthesis/graft use in pelvic surgery utilize the category-time-site system. The system's limited and inconsistent use hinders the ability to draw conclusions useful for clinical practice. Effort should be directed toward improving appropriate usage or revising the system to increase its exposure in related publications. An improved system will better prepare pelvic surgeons for assessing future generations of prostheses/grafts.

Use of synthetic grafts in pelvic reconstruction: A path of continued discovery

Since the 1990s, mesh has been used in pelvic reconstruction to augment repairs for stress urinary incontinence and pelvic organ prolapse (POP). In 2008 and 2011, the United States Food and Drug Administration (FDA) issued Public Health Notifications ultimately informing providers and the public that complications associated with the use of synthetic mesh in the transvaginal repair of POP are not rare. In this review, we (1) examine literature characterizing surgical practice-patterns subsequent to the FDA announcements; (2) describe presentation of mesh-associated complications and outcomes of management; (3) discuss the most recent materials science research; and (4) seek to characterize whether or not mesh has lived up to the long-term efficacy promise of a permanent implant. Durability of mesh-augmented anatomical outcomes do not consistently translate into improved patient satisfaction and subjective outcomes. This, when coupled with the possibility of mesh-associated complications, emphasizes the need for continued innovation beyond the status quo of current synthetic grafts.

Management of complications of mesh surgery

PURPOSE OF REVIEW

Transvaginal placements of synthetic mid-urethral slings and vaginal meshes have largely superseded traditional tissue repairs in the current era because of presumed efficacy and ease of implant with device 'kits'. The use of synthetic material has generated novel complications including mesh extrusion, pelvic and vaginal pain and mesh contraction. In this review, our aim is to discuss the management, surgical techniques and outcomes associated with mesh removal.

RECENT FINDINGS

Recent publications have seen an increase in presentation of these mesh-related complications, and reports from multiple tertiary centers have suggested that not all patients benefit from surgical intervention.

SUMMARY

Although the true incidence of mesh complications is unknown, recent publications can serve to guide physicians and inform patients of the surgical outcomes from mesh-related complications. In addition, the literature highlights the growing need for a registry to account for a more accurate reporting of these events and to counsel patients on the risk and benefits before proceeding with mesh surgeries.

Heterogeneity in post-intervention prolapse and urinary outcome reporting: a one-year review of the International Urogynecology Journal

INTRODUCTION

This review aimed to examine post-intervention prolapse, incontinence, and overactive bladder outcome measures published in the International Urogynecology Journal over the previous year and to report on the heterogeneity in outcome reporting.

METHODS

All original article abstracts published in the print version of the International Urogynecology Journal in 2014 were reviewed for possible inclusion. Those reporting on prolapse and/or incontinence and/or overactive bladder outcomes following a urogynecological intervention were analyzed. Articles were reviewed for all reported outcomes. Outcomes were categorized as primary or secondary and objective or subjective.

RESULTS

Of 117 original articles published, 45 were reviewed. Among primary outcomes, 9 different outcomes were reported for prolapse and 11 for incontinence and overactive bladder. For prolapse, 6 different objective and 13 subjective outcomes were reported. For incontinence, 21 objective and 36 subjective outcomes were reported. Three different definitions were used for the outcome of "prolapse cure," 3 for "prolapse recurrence," and 4 for "stress incontinence cure." Several validated and non-validated questionnaires in addition to single unvalidated questions were used to measure subjective outcomes.

CONCLUSIONS

This research highlights the diversity in outcome reporting for prolapse, incontinence, and overactive bladder after an intervention in the last year of publications alone. This can lead to serious challenges in the generation of higher order evidence, such as systematic reviews and meta-analyses. As a subspecialty, we need to aim for more cohesive reporting so as to allow for robust comparison and evidence dissemination.

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.

Clinical application of IUGA/ICS classification system for mesh erosion

AIMS

Our aim was to assess the usability of the IUGA/ICS classification system for mesh erosion in a tertiary clinical practice and to determine if assigned classification is associated with patient symptoms, treatment, and outcome.

METHODS

We retrospectively identified women who had mesh erosion after prolapse or incontinence surgery. Each erosion was classified using the IUGA/ICS category time site (CTS) system. Associations between classification and presenting symptom (asymptomatic, pain, bleeding, voiding, or defecatory dysfunction, infection, prolapse), treatment type, and outcome were evaluated with chi-squared test, student's t-test, and univariate logistic regression.

RESULTS

We identified 74 subjects with mesh erosion; only 70% were classifiable. Asymptomatic patients (n = 19) (Category A) were more likely to be managed conservatively (P = 0.001). Symptomatic patients (n = 55) (Category B) were more likely to be managed surgically (P = 0.003). Other variables had no association with treatment. No variables were associated with outcome. Presenting symptom was associated with both treatment (P = 0.005) and outcome (P = 0.03). Asymptomatic subjects were more likely to have satisfactory outcome (P = 0.03). Urinary frequency and urgency were highly correlated with surgical management (P = 0.02).

CONCLUSIONS

One third of mesh erosions could not be retrospectively coded using the IUGA/ICS classification. The components of the system were not predictive of treatment nor outcome with exception of the Category A (asymptomatic) and Category B (symptomatic). Asymptomatic women with mesh erosion can be successfully managed with conservative measures. Use of a classification system may be enhanced if the system is simplified by limiting the number of variables to those associated with interventions and patient outcome. Neurourol. Urodynam. 35:589-594, 2016. © 2015 Wiley Periodicals, Inc.

Vaginal native tissue repair versus transvaginal mesh repair for apical prolapse: how utilizing different methods of analysis affects the estimated trade-off between reoperation for mesh exposure/erosion and reoperation for recurrent prolapse

INTRODUCTION AND HYPOTHESIS

Informed decision-making about optimal surgical repair of apical prolapse with vaginal native tissue (NT) versus transvaginal mesh (TVM) requires understanding the balance between the potential "harm" of mesh-related complications and the potential "benefit" of reducing prolapse recurrence. Synthesis of data from observational studies is required and the current literature shows that the average follow-up for NT repair is significantly longer than for TVM repair. We examined this harm/benefit balance. We hypothesized that using different methods of analysis to incorporate follow-up time would affect the balance of outcomes.

METHODS

We used a Markov state transition model to estimate the cumulative 24-month probabilities of reoperation for mesh exposure/erosion or for recurrent prolapse after either NT or TVM repair. We used four different analytic approaches to estimate probability distributions ranging from simple pooled proportions to a random effects meta-analysis using study-specific events per patient-time.

RESULTS

As variability in follow-up time was accounted for better, the balance of outcomes became more uncertain. For TVM repair, the incremental ratio of number of operations for mesh exposure/erosion per single reoperation for recurrent prolapse prevented increased progressively from 1.4 to over 100 with more rigorous analysis methods. The most rigorous analysis showed a 70% probability that TVM would result in more operations for recurrent prolapse repair than NT.

CONCLUSIONS

Based on the best available evidence, there is considerable uncertainty about the harm/benefit trade-off between NT and TVM for apical prolapse repair. Future studies should incorporate time-to-event analyses, with greater standardization of reporting, in order to better inform decision-making.

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.