Joint position statement on the management of mesh-related complications for the FPMRS specialist

Unilateral J-cut division versus partial and subtotal removal techniques in female patients with mesh-related urethral obstruction: Multicentric comparative study

Objective

To compare the functional (obstruction relieving) outcomes and complications of unilateral J-cut division, partial and subtotal vaginal removal techniques were performed for mesh-related urethral obstruction (MRUO) in females.

Methods

Patient review included demographics, a medical history and proforma with details of lower urinary tract symptoms (LUTS), physical and urodynamic findings, detailed surgical reports and follow-up data. Variables were compared between the three groups.

Results

Out of 130 patients with sling revision surgery (SRS), 54 women underwent SRS for MRUO with a median follow-up of 48 (17-96) months. Unilateral J-cut division, partial and subtotal vaginal removal techniques were performed in 12, 31 and 11 patients with a median duration of surgery of 30 (25-34), 40 (35-56) and 60 (60-70) minutes, respectively (p = 0.001). Statistically significant increase in median maximum free urine flow rate and decrease in median post-void residual urine volume were found after SRS in the three groups, while de novo stress urinary incontinence (SUI) developed in 10%, 44% and 60% of the patients in the unilateral J-cut division, partial and subtotal removal groups, respectively (p = 0.007).

Conclusions

The unilateral J-cut division technique was as effective as the partial and subtotal vaginal removal techniques in relieving MRUO with a shorter duration of surgery time (p = 0.001) and lower risk of de novo SUI (p = 0.007). Comparative studies with a larger number of patients are needed.

Robotic-assisted intravesical mesh excision following retropubic midurethral sling

INTRODUCTION AND HYPOTHESIS

Intravesical mesh is an uncommon complication following synthetic midurethral sling placement. Management options have included endoscopic techniques such as laser ablation or surgical excision. We present our technique for robotic-assisted excision of intravesical mesh following a retropubic midurethral sling.

METHODS

The patient is a 66-year-old woman with a remote history of laser ablation of intraurethral mesh after midurethral sling, and persistent symptomatic intravesical mesh with associated stone at the bladder neck and right bladder wall. Robotic excision of the intravesical mesh and stone was performed by entering the space of Retzius, carrying the dissection along the right arm of the retropubic sling, performing two cystotomies to free and remove the mesh, and finally closing the cystotomies in two layers.

RESULTS

The patient was discharged on postoperative day 1. A cystogram prior to catheter removal showed no extravasation and a competent bladder neck. She reported no new stress incontinence and had improvement in overactive bladder symptoms.

CONCLUSIONS

Robotic excision of intravesical mesh after synthetic midurethral sling was safely performed in this patient who had multiple areas of intravesical mesh. Management aspects reported here may be helpful for complex presentations of intravesical mesh.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines).

PREOPERATIVE PATIENTS' INFORMATION

Each patient must be informed concerning the risks associated with POP surgery (EO).

HEMORRHAGE, HEMATOMA

Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO).

BLADDER INJURY

When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO).

URETER INJURY

After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO).

RECTAL INJURY

Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO).

VAGINAL WALL INJURY

After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO).

MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS)

Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient.

BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM

Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO).

URINARY RETENTION

Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO).

POSTOPERATIVE PAIN

Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO).

POSTOPERATIVE DYSPAREUNIA

When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO).

VAGINAL MESH EXPOSURE

To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO).

SUTURE THREAD VAGINAL EXPOSURE

For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed.

BLADDER AND URETERAL MESH EXPOSURE

When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Dysregulated inflammatory response to urogynecologic meshes in women with diabetes and its implications

BACKGROUND

Diabetes is an independent risk factor for mesh complications in women undergoing mesh-augmented surgical repairs of stress urinary incontinence and/or pelvic organ prolapse. The underlying mechanism remains unclear.

OBJECTIVE

This study aimed to define the diabetes-associated alterations in the host inflammatory response to mesh and correlate them with perioperative glucose management.

STUDY DESIGN

Deidentified demographics and medical records of patients who underwent mesh removal and participated in a mesh biorepository study were reviewed (n=200). In patients with diagnosed diabetes (n=25), blood glucose management before initial mesh implantation and before and after mesh removal was assessed by blood glucose and hemoglobin A1c levels. Age- and body mass index-matched tissue samples excised from patients with and without diabetes were examined. Transcriptomic profiles of immune cell markers, immune mediators, key inflammatory regulators, cell senescence, and epigenetic enzymes were determined by multiplex transcriptomic assays (NanoString). Ratios of apoptotic cells to CD68+ macrophages were examined with immunofluorescence. Protein profiles of 12 molecules involved in apoptotic cell clearance were examined with a multiplex protein assay (Luminex).

RESULTS

Demographic and clinical characteristics, including duration between mesh implantation and removal, reason for removal, and type of mesh, etc., were comparable between patients with and without diabetes, except for 11.6% higher body mass index in the former (P=.005). In patients with diabetes, suboptimal management of blood glucose following mesh implantation was observed, with 59% of the patients having loosely or poorly controlled glucose before and after the mesh removal. Ongoing chronic inflammatory response was observed in the excised mesh-tissue complexes in both groups, whereas markers for M2 macrophages (Mrc1 [mannose receptor C-type 1]) and helper T cells (Cd4 [CD4 molecule]) were increasingly expressed in the diabetic vs nondiabetic group (P=.023 and .047, respectively). Furthermore, the gene expressions of proinflammatory Ccl24 (C-C motif chemokine ligand 24) and Ccl13 (C-C motif chemokine ligand 13) were upregulated by 1.5- and 1.8-fold (P=.035 and .027, respectively), whereas that of Il1a (interleukin 1 alpha) was paradoxically downregulated by 2.2-fold (P=.037) in the diabetic vs nondiabetic group. Interestingly, strong positive correlations were found between the expression of Ccl13, Setdb2 (SET domain bifurcated histone lysine methyltransferase 2), and M2 macrophage markers, and between the expression of Il1a, Fosl1 (activator protein-1 transcription factor subunit), and dendritic cell markers, suggesting the involvement of macrophages and dendritic cells in the diabetes-dysregulated proinflammatory response. Supportively, apoptotic cell clearance, which is an important function of macrophages, appeared to be impaired in the diabetic group, with a significantly increased protein level of CALR (calreticulin), an "eat-me" signal on the surface of apoptotic cells (P=.031), along with an increase of AXL (AXL receptor tyrosine kinase) (P=.030), which mediates apoptotic cell clearance.

CONCLUSION

Diabetes was associated with altered long-term inflammatory response in complicated mesh implantation, particularly involving innate immune cell dysfunction. Suboptimal blood glycemic control following mesh implantation may contribute to this immune dysregulation, necessitating further mechanistic studies.

Pain resolution and functional outcomes of total mesh excision: a case series

INTRODUCTION AND HYPOTHESIS

The objective was to assess the impact of total excision of polypropylene midurethral slings (MUS) on patient pain levels and to report on functional outcomes including recurrent/de novo stress urinary incontinence (SUI), sexual function, and quality of life measures.

METHODS

This is a retrospective analysis of patients who underwent total MUS excision from March 2017 to December 2019. The primary outcome was the impact on pain assessed by a Numeric Rating Scale (NRS). Questionnaires analyzed were: Pain Catastrophizing Scale, Pelvic Floor Distress Inventory Short Form-20, Female Sexual Function Index, and McGill Pain Index questionnaires.

RESULTS

Thirty-two women underwent total mesh excision within the inclusion period; with follow-up data available for 31 out of 32; 14 (43.8%) had previously undergone one or more partial vaginal mesh excision procedures. Types of MUS removed were: 14 (43.8%) transobturator midurethral slings, 12 (37.5%) retropubic midurethral slings, 4 (12.5%) mini-slings, and 2 (6.3%) mesh slings placed by laparotomy. Pain was the main reason for referral in 31 patients (96.9%). Mean pain NRS reduced from 6.1 pre-operatively to 3.3 post-operatively, with paired comparison showing a significant difference (p<0.01). Qualitatively, complete symptoms resolution was observed in 10 out of 31 (32.3%), another 9 out of 31 (29.0%) patients experienced clinically significant improvement, 2 out of 31 (6.5%) did not experience improvement in pain, and 10 out of 31 (32.3%) reported new/worsening pain. Post-operative complications occurred in 9 (29.0%) patients; all were Clavien-Dindo grade II. Nineteen (61.3%) reported de novo/recurrent SUI post-operatively.

CONCLUSION

Total MUS mesh excision yields high complication and SUI recurrence rates, counter-balanced by a 61.3% pain resolution/improvement rate. These data are pertinent for patient counseling.

Cystoscopic removal of transvaginal mesh: Long-term outcomes

Objectives

This study's aim is to evaluate the long-term quality of life and functional outcomes following cystoscopic excision of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) mesh extruded into the urinary tract in women.

Patients and Methods

A retrospective chart review was performed of all cases of cystoscopic removal of extruded mesh at our high-volume tertiary care centre between April 2013 and August 2021. Postoperative patient-reported outcomes were collected via questionnaires: Urogenital Distress Inventory Short Form (UDI-6), EQ-5D-5L Visual analogue scale, ICIQ-Satisfaction (ICIQ-S) and additional questions regarding postoperative sexual function.

Results

During the study period, 27 women with a median age of 61 years (45-87) underwent cystoscopic mesh removal surgery using either Ho-YAG laser (56%) or bipolar loop resection (44%). The most common presentation of mesh extrusion was recurrent urinary tract infections (67%). Other presenting complaints were pain (41%), urinary urgency ± incontinence (41%) and voiding difficulties (18%). Long-term follow-up outcomes from 20 patients (median follow-up: 24 months) showed that mesh removal was rated successful by 80%, and 100% would choose to have the surgery again if in the same situation. Recurrent SUI was reported by 45% of respondents, and urinary urge incontinence was found in 50%. For patients who answered the sexual function questions, 50% reported improved sexual function postmesh removal (6/12).

Conclusions

Cystoscopic removal of extruded female SUI and POP mesh is associated with high patient satisfaction and low morbidity in appropriately selected patients at 2-year median follow-up. A patient-centred shared decision-making process is essential in counselling patients regarding options and expected outcomes following mesh removal surgery.

Long-term Data on Graft-Related Complications After Sacrocolpopexy With Lightweight Compared With Heavier-Weight Mesh

OBJECTIVE

To estimate the long-term incidence and characteristics of graft-related complications, rate of reintervention for graft-related complications and prolapse, and subjective and anatomical outcomes after laparoscopic sacrocolpopexy with heavier-weight (more than 44 g/m2) compared with lightweight (28 g/m2) polypropylene mesh, the latter with resorbable poliglecaprone component.

METHODS

We conducted a single-center study that compared two consecutive prospective cohorts of patients who were undergoing laparoscopic sacrocolpopexy for symptomatic stage 2 or greater cervical or vault prolapse, by using either heavier-weight polypropylene mesh or lightweight polypropylene mesh at a similar duration of follow-up. The primary outcome was the occurrence of graft-related complications and their nature. Secondary outcomes included reinterventions for graft-related complications, recurrent apical prolapse, a subjective outcome (PGIC [Patient Global Impression of Change] score 4 or higher), and an anatomical outcome (point C -1 cm or greater).

RESULTS

We identified consecutive patients: 101 were implanted with heavier-weight polypropylene, and 238 were implanted with lightweight polypropylene; all were audited at comparable follow-up times (heavier-weight mesh: 97 months [interquartile range 16 months]; lightweight mesh: 92.5 months [interquartile range 58 months]). Graft-related complications were more frequent in patients with heavier-weight than lightweight mesh (22.8% [23/101] vs 7.3% [13/178]; hazard ratio [HR] 3.3, 95% CI 1.6-7.1), more frequently symptomatic (heavier-weight mesh: 16.8% [17/101] vs lightweight mesh: 2.8% [5/178]; HR 6.0, 95% CI 2.5-14.3), and more frequently lead to reintervention for graft-related complications (heavier-weight mesh: 18.8% [19/101] vs lightweight mesh: 2.1% [5/238]; HR 4.6, 95% CI 1.9-11.2). The vast majority of patients improved (PGIC score 4 or higher), without difference between groups (heavier-weight mesh: 71/84 [84.9%]; lightweight mesh: 154/178 [86.5%]; HR 0.8, 95% CI 0.6-1.1); neither was there a difference in anatomical failure rate (heavier-weight mesh: 1/60 [1.7%] vs lightweight mesh: 8/131 [6.1%]; HR 0.3, 95% CI 0.1-1.4). Reoperations for recurrent vault prolapse were scarce (0.0% in heavier-weight mesh, vs 0.4% in lightweight mesh).

CONCLUSION

In two consecutive cohorts, the number of graft-related complications, symptomatic graft-related complications, and reinterventions for graft-related complications were higher in patients implanted with heavier-weight polypropylene than when lightweight polypropylene was used. There were no differences in subjective, objective outcomes, and reoperation rates for prolapse.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04378400.

FUNDING

To assist in this audit, the University Hospitals Leuven received support from Ethicon Endosurgery.

The impact of surgeon operative volume on risk of reoperation within 5 years of mid-urethral sling: a systematic review

INTRODUCTION AND HYPOTHESIS

Undesired outcomes after mid-urethral sling (MUS), such as mesh exposure or surgical failure, can necessitate further procedures. The objective of this review is to evaluate the association between surgeon operative volume and the risk of reoperation after MUS.

METHODS

Eligible studies were selected through an electronic literature search from database and references of the studies included. Databases were searched for original studies reporting on the MUS procedure, reoperation, and operative volume. Random effects models were used to estimate the pooled OR of reoperation according to surgeon volume. Outcomes were divided into two categories: mesh removal and/or revision and subsequent surgery for treatment of SUI.

RESULTS

A total of 2,304 abstracts were screened, and 51 studies were assessed through full-text reading. Seven studies were included in the systematic review. High-volume and low-volume surgeons were defined differently in various studies. The odds ratio of the mesh removal/revision procedure was 1.26 (95%CI 1.03-1.53) among those who received their surgery from a low-volume surgeon compared with those who received their surgery from a high-volume surgeon as defined by the studies. The odds ratio of repeated incontinence procedures was 1.18 (95% CI 1.01-1.37).

CONCLUSIONS

The odds of a repeat incontinence procedure appear higher if the surgery is performed by a low-volume surgeon, although these results need to be interpreted with caution as the definition of low-volume vs high-volume surgeon varied between studies. As such, operative volume should be included in surgical reporting, and future research should utilize surgical volume as either a continuous exposure or a standardized value of low- vs high-volume MUS surgeons.

Clinical outcome and urodynamic changes of tailored transvaginal mesh surgery for pelvic organ prolapse: A mid-term 40 Months follow-up

PURPOSE

To evaluate the changes in clinical outcome and urodynamic parameters after tailored anterior transvaginal mesh (ATVM) surgeries in a mid-term follow-up.

METHODS

Between November 2011 and December 2015, women with ≥stage II pelvic organ prolapse (POP) who underwent ATVM surgeries were retrospectively reviewed. The data-reviewing timeframe was until December 2021. Clinical and urodynamic diagnoses regarding urinary symptoms were evaluated before and after the operation.

RESULTS

A total of 160 women were included. Stress urinary incontinence decreased significantly after the operation (99% (159/160) vs. 43% (68/160), p < 0.01), as well as the pad weight (20.5 ± 2.7 vs. 9.4 ± 2.0, p < 0.001) and diagnosis of urodynamic stress incontinence (83% (132/160) vs. 51% (82/160), p < 0.01). Overactive bladder syndrome increased significantly after the operation (18% (29/160) vs. 28% (45/160), p = 0.03), even though the objective parameters, such as first and strong desire to void, bladder oversensitivity, and detrusor overactivity, were all improved after the operation. The pad weight was mostly improved significantly within the first postoperative 2 years. Eighteen (11%) women had global recurrent POP, and only one (0.6%) woman had true recurrence of cystocele. Twenty-four (15%) women had mesh extrusion, and two-thirds of them could be managed in an office setting.

CONCLUSIONS

In women with advanced cystocele, the ATVM surgery provides a favorable anatomic reduction outcome with an acceptable mesh extrusion rate. The ATVM provides an anti-incontinence effect, both in subjective symptoms and objective parameters, but this effect might decline after postoperative 2 years.

Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings

OBJECTIVE

To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal.

METHODS

We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009-2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed.

RESULTS

87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P = 0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P = 0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%).

CONCLUSION

Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.

Early experience of transabdominal and novel transvaginal robot-assisted laparoscopic removal of transvaginal mesh

Background Mesh removal following transvaginal mesh placement has typically involved transvaginal, open pelvic, laparoscopic or a combination of approaches. Robotic pelvic mesh removal has been described in a small number of cases only. This study aims to determine the feasibility and safety of using robot-assisted laparoscopic surgery in removal of pelvic mesh via trans-abdominal and novel trans-vaginal approach. Materials and methods This is a prospective case series study on women who underwent transabdominal or transvaginal robot-assisted removal of pelvic mesh. Women were offered participation in this study if they were over the age of 18 with pelvic mesh and a clinical indication for mesh removal. Alternative surgical options including conventional open removal of mesh were discussed and offered to patients. The primary outcome of this study is the rate of successful removal of mesh and the 30-day complication rates. Ethics approval was obtained for this study. Results Thirty patients were included in this study. Median age was 62. Median operative and console time was 240 and 148 minutes, respectively. Concomitant reconstructive procedures were performed in 40% of patients. Complete or near-complete mesh removal was achieved in 83.3% of patients. For the remaining patients, partial removal of mesh was performed as planned pre-operatively. Three Clavien-Dindo grade 3b complications resulted from mesh removal: concomitant ureteric and bladder injury, omental bleed and groin wound infection. Conclusion This study presents the early experience of robotic-assisted removal of transvaginal mesh with a transvaginal or transabdominal approach and demonstrated feasibility of removal of both retropubic and transobturator MUSS as well as trans-vaginal prolapse meshes with transobturator and sacrospinous mesh arms. Further studies are required to expand understanding on the learning curve, operating times, complication rates and functional outcome of this operation.

Robotic mesh-supported pectopexy for pelvic organ prolapse: expanding the options of pelvic floor repair

Pelvic organ prolapse affects 30-50% of the female population. For definitive treatment surgery is unavoidable. Sacrocolpopexy has been the gold standard for anatomical correction of pelvic organ prolapse since the 1990s. Recently, pectopexy has been introduced as a new surgical procedure to correct apical prolapse. We have translated the laparoscopic pectopexy into a robotic procedure. The charts of the first 30 consecutive patients who underwent robotic pectopexy at the department for robotic and pelvic floor surgery were reviewed. All patients were analyzed for estimated blood loss, operation time, as well as complications. Treatment success was evaluated after 3-6 months using a composite endpoint including anatomical and subjective components. Of the 30 patients analyzed, 18 underwent hysteropectopexy (n = 18), 6 patients underwent vaginopectopexy and 6 patients underwent cervicopectopexy. Additional procedures were performed in 14 patients, and this influenced operation time and intraoperative blood loss. No intraoperative complications were noted and no conversions were necessary. Treatment success according to the primary composite endpoint was achieved in 30 (100%) patients. Furthermore, neither de novo urgency nor obstructive bowel symptoms were noted in any of the patients treated with robotic pectopexy. Similar to SCP, pectopexy is designed for prolapse repair. The robotic technique for pectopexy capitalizes on the advantages of robotic surgery as compared to conventional laparoscopy since it allows for anatomical preparation and simplification of applying sutures and mesh material, reducing operating time and minimizing surgical trauma. The technique is safe, and anatomical outcomes are excellent.

Marjolin's Ulcer: Mesh-Related Vaginal Cutaneous Fistula With Superimposed Osteomyelitis and Neoplastic Transformation

Marjolin's ulcer is a rare, often aggressive squamous cell malignancy identified in previously injured areas or those affected by chronic inflammation. It often develops in deep wounds that are slow to heal or allowed to heal by secondary intention. Few reports and small case series about Marjolin's ulcer have been published. We present a unique case with well-differentiated keratinized squamous cell carcinoma arising from a mesh-related vaginocutaneous fistula with superimposed osteomyelitis. The risk of cancerous transformation leading to Marjolin's ulcer in non-healing traumatic wounds is 8.1% and 2.6% in a fistula associated with purulent-inflammatory bone diseases. Approximately 1.7% of chronic cutaneous ulcers undergo neoplastic transformation, with a disposition to squamous cell carcinoma. Women experiencing mesh complications may require multiple procedures to address these issues and, therefore, should have them addressed in a timely manner to allow for the best patient outcome. Treatment optimization on a whole should incorporate the goals outlined by the American Urogynecologic Society and the International Urogynecological Association. These include the use of relevant evidence to help guide the management of mesh complications as well as identifying the gaps in currently available evidence, developing a treatment algorithm to be used for shared decision making, and identifying provider and healthcare facility characteristics that may optimize treatment outcomes specific to mesh complications.

Current situation of complications related to reconstructive surgery for pelvic organ prolapse: a multicenter study

Introduction and hypothesis

This study aimed to investigate the evaluation and management of complications after pelvic floor reconstructive surgery for pelvic organ prolapse in China.

Methods

Complications of pelvic floor reconstructive surgery for pelvic organ prolapses from 27 institutions were reported from November 2017 to October 2019. All complications were coded according to the category-time-site system proposed by the International Urogynecological Association (IUGA) and the International Continence Society (ICS). The severity of the complications was graded by the Clavien-Dindo grading system. Four scales were used to evaluate patient satisfaction and quality of life after management of the complications: the Patient Global Impression of Improvement (PGI-I), the Pelvic Floor Impact Questionnaire Short Form (PFIQ-7), the Pelvic Organ Prolapse Symptom Score (POP-SS), and a 5-point Likert-type scale that evaluated the patient’s choice of surgery.

Results

Totally, 256 cases were reported. The occurrence of complications related to transvaginal mesh (TVM) and laparoscopic sacrocolpopexy (LSC) had a significantly longer post-surgery delay than those of native tissue repair surgery (p < 0.001 and p = 0.010, respectively). Both PFIQ-7 and POP-SS score were lower after management of complications (p < 0.001). Most respondents (81.67%) selected very much better, much better, or a little better on the PGI-I scale. Only 13.3% respondents selected unlikely or highly unlikely on the 5-point Likert-type scale.

Conclusions

The occurrence of complications related to TVM surgery and LSC had a longer post-surgery delay than native tissue repair surgery. Long-term regular follow-up was vital in complication management. Patient satisfaction with the management of TVM complications was acceptable.

Rates of Sling Procedures and Revisions-A National Surgical Quality Improvement Program Database Study

OBJECTIVE

The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication.

METHODS

This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant.

RESULTS

During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = -0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = -0.49, -P = 0.51).

CONCLUSIONS

Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.

Listening to Women: A Qualitative Analysis of Experiences after Complications from Mesh Mid-urethral Sling Surgery

OBJECTIVE

To gain a detailed understanding of women's experiences after undergoing revision surgery for mesh mid-urethral sling (MUS) complications, qualitatively organize those experiences, and present insights as potential springboards for future research.

METHODS

We conducted a series of semistructured focus groups and interviews of patients who had undergone mesh MUS revision surgery at a single tertiary referral institution. Discussions were recorded, transcribed, de-identified, and analyzed using deductive and inductive content analysis. Two researchers independently performed line-by-line coding and 2 additional researchers reviewed the codes and transcripts as an audit.

RESULTS

Nineteen women participated in the study. Complications from mesh MUS surgery impacted participants psychologically, socially, sexually, and physically. Participants recounted that risks and alternatives to MUS surgery were understated during the informed consent process whereas benefits were overstated. Participants shared insights into negative and positive ways surgeons responded to postoperative complications and how their experiences impacted the patient-surgeon relationship.

CONCLUSION

The impact of complications from mesh MUS surgery is broad and can involve multiple domains of a woman's life. Improved pre-operative patient preparedness, empathetic response toward patients who present with complications, prompt referral to surgeons with experience in mesh MUS complications and multidisciplinary care will likely improve the patient experience and can serve as foci for future studies.

It's not that mesh, is it? What providers should know about the transvaginal mesh controversy

The U.S. Food and Drug Administration recent ban on surgical mesh intended for the transvaginal repair of pelvic organ prolapse has called into question the safety of surgical mesh implants in general. As the media firestorm around vaginal mesh kits has continued to grow, important details about the specific type of mesh involved have been lost in the public discourse surrounding the controversy. This has left healthcare providers across the nation in the difficult position of addressing patient anxieties about the use of mesh in gynecologic surgery. This review seeks to educate women's health providers on the historical background and various uses of the different types of mesh in gynecologic surgery.

[Surgical management of suburethral sling complications and functional outcomes]

OBJECTIVES

To identify various clinical presentation leading to the diagnosis of mid-urethral sling (MUS) complications and to analyze the functional outcomes after surgical management of these complications.

METHOD

Retrospective observational monocentric study of all patients treated by MUS section or removal, between December 2005 and October 2019, in a pelviperineology centre.

RESULTS

During this study, 96 patients were included. MUS complications surgically managed were vaginal mesh exposure (48 %), urethral mesh exposure (17 %), bladder mesh exposure (10 %); dysuria (30 %), pain (6 %), and infection (3 %). The mean time to diagnosis was 2 years. This diagnosis delay was caused by a non-specific and heterogeneous symptomatology. Surgical management consisted in MUS partial removal (79 %) and MUS simple section (21 %) with low perioperative morbidity. At three months follow-up, 36 patients (53 %) had stress urinary incontinence (SUI), including 13 (19 %) de novo (meaning no SUI before MUS section/removal) and 19 (28 %) had overactive bladder, including 9 (13 %) de novo. Half of the patients with SUI after MUS section/removal were able to be treated by a second MUS with a success rate of 83 % at 3 years.

CONCLUSION

Clinical presentation of MUS complications is heterogeneous. Surgical treatment was associated with low morbidity in our study. Post-operatively, half of the patients had SUI and a second MUS was a relevant treatment option after proper evaluation.

LEVEL OF EVIDENCE

4.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case-Control Study

OBJECTIVE

To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion.

MATERIALD AND METHODS

This is a case-control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion.

RESULTS

In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m² (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m² (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]).

CONCLUSION

Smoking status, age under 55 years, BMI below 30 kg/m², fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.