Tobacco use, immunosuppressive, chronic pain, and psychiatric conditions are prevalent in women with symptomatic mesh complications undergoing mesh removal surgery

Associations Between Short-Term Postoperative Outcomes and Immunocompromised Status in Patients Undergoing Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Few data exist on the impact of immunosuppression on perioperative outcomes in women undergoing sacrocolpopexy. The objective of this study was to compare differences in 30-day perioperative morbidity in immunocompromised versus non-immunocompromised women undergoing sacrocolpopexy (SCP). We hypothesize that compared with the non-immunocompromised group, immunocompromised women undergoing SCP experience worse composite 30-day postoperative outcomes.

METHODS

Retrospective cohort of female patients aged 18 years or older who underwent sacrocolpopexy from 2012 to 2017. Current procedural terminology (CPT) codes 57280 and 57425 identified sacrocolpopexy in the American College of Surgeons-National Surgical Quality Improvement Project database. The primary exposure was a binary indicator of immunocompromised status, and the primary outcome was a composite indicator of readmission, reoperation, or a severe adverse event 30 days after surgery. Marginal standardization, a G-computation method, was used to estimate risk ratios (RR) and 95% confidence intervals (CI) representing the association between exposure and outcome.

RESULTS

A total of 13,505 women underwent SCP between 2012 and 2017. Of those, 2,625 (19.4%) had an indicator of immunocompromised status, with diabetes and smoking being most common. The risk of the composite adverse outcome in immunocompromised women was 7.3% versus 4.6% in non-immunocompromised women. After adjusting for age, race, ethnicity, and body mass index, immunocompromised women experienced 54% increased relative risk of an adverse outcome, compared with non-immunocompromised women (RR = 1.54; 95% CI: 1.31, 1.82).

CONCLUSIONS

Immunocompromised status, most commonly caused by diabetes and smoking, increases the risk of readmission, reoperation, and a severe adverse event within 30 days of sacrocolpopexy.

Urethral Bulking

OBJECTIVE

This Clinical Practice Statement aims to provide clinicians with evidence-based guidance for the use of urethral bulking agents (UBAs) in the treatment of stress urinary incontinence (SUI).

METHODS

We conducted a structured search of the English literature published from January 1960 to November 2022. Search terms identified studies of both current and historic UBAs. Data extracted at the time of full-text review included type of study, research setting, number of participants, age group, bulking agent, primary outcome, secondary outcome, efficacy, and complications.

RESULTS

One thousand five hundred ninety-four nonduplicate articles were identified using the search criteria. After limiting the article types to randomized control led trials, prospective studies, guideline documents, reviews, meta-analyses, and case reports of complications, 395 studies were screened.

CONCLUSIONS

Based on our findings, we propose the following recommendations for clinicians when considering UBA: First, UBA is indicated in cases of demonstrable SUI. Intrinsic sphincter deficiency is not predictive of patient outcomes. Second, patients should be counseled on the risks, lack of long-term efficacy data, potential need for repeat injections, possible need for surgery for recurrent SUI, implications for future procedures, and pelvic imaging findings that may be observed after UBA. Third, UBA may be considered for initial management of SUI. Fourth, UBA is an option for patients with persistent or recurrent SUI after a sling procedure. Fifth, clinicians may prioritize UBA over surgery in specific patient populations. Sixth, polyacrylamide hydrogel demonstrates marginally improved safety and durability data over other available agents.

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair

PURPOSE

With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery.

METHODS

Clinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction.

RESULTS

The multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified.

CONCLUSION

A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

Twisting of transobturator midurethral slings: does it matter?

INTRODUCTION AND HYPOTHESIS

We assessed rotation/twisting of transobturator midurethral slings (TOTs) and tested for associations with de novo chronic pain and voiding dysfunction.

METHODS

A retrospective pilot study including patients seen after Monarc™ TOT surgery at a single tertiary hospital in 2005-2016. Patients underwent an interview, clinical examination, uroflowmetry and 4D pelvic floor ultrasound. Volume datasets were analyzed blinded against all other data. Sling rotation/twisting was evaluated in volumes obtained at rest. The sling axis was measured relative to the vertical in the midline and in the most lateral parasagittal slice. Total sling rotation was calculated by summation of absolute angle differences between midline and lateral angles. "Corkscrew" rotation was noted when direction of rotation was opposite on the contra-lateral side.

RESULTS

The study included 215 patients. Fifty-two (24%) were excluded, leaving 163. Mean age was 57 years (28-87; SD 12), mean BMI 29.4 kg/m² (18.3-47.4, SD 6). Follow-up was at a median of 17 months (IQR 11-27). Chronic de novo pain was reported by 15 women (9%; dyspareunia by 11 and pelvic/vaginal pain by 4). On imaging, mean total sling rotation was 144° (12-335, SD 56). In the majority (n = 103, 63%) it rotated counter-clockwise from its midline position and in 30 (18%) it rotated clockwise. "Corkscrew" rotation was noted in 30 (18%). De novo chronic pain was associated with lower BMI and vaginal sling exposure but not with sling rotation. The latter was not found to be associated with voiding dysfunction either.

CONCLUSIONS

Monarc™ TOTs rotate considerably throughout their course. The degree of twisting or rotation and its direction was not found to be associated with de novo postoperative chronic pain or voiding dysfunction.

Pain after midurethral sling; the underestimated role of mesh removal

Introduction

The primary aim of this study was to evaluate the results of midurethral sling (MUS) removal in women who have pain as their single complication of MUS.

Material and methods

We performed a retrospective chart study supplemented with a cross sectional questionnaire. Women who underwent MUS removal for pain as the solitary reason for removal between 2004 and 2018 were included. Primary outcome was change in pain levels assessed by the visual analogue scale (VAS) pain score (range 0–10). Secondary outcome was the recurrence of stress urinary incontinence (SUI).

Results

Twenty-six of 31 patients returned the questionnaire. Median medical file follow-up was 12 months (range 2–66) and 25 months (range 5–104) regarding questionnaires. VAS pain score dropped from 7.8 (SD 1.9) at baseline to 4.5 (SD 3.2) at follow-up (p <.00). Seven (23%) patients were pain-free. Patients undergoing partial vaginal resection (n = 6) had a VAS pain score decrease of 4.7 (p = .02) versus 2.7 (p = .02) for complete vaginal removal (n = 14). Twenty-three (89%) patients experienced SUI at follow-up, whereof 10 (45%) reported (almost) no incidents of SUI.

Conclusions

MUS removal is a viable and safe option with a significant drop in VAS pain score in patients with chronic pain after MUS placement. A post-operative increase of SUI and a possible renewed wish for SUI treatment have to be considered. This should not be a reason to refrain from information and/or referral for surgical removal.

The Long-Term Impact of Vaginal Surgical Mesh Devices in UK Primary Care: A Cohort Study in the Clinical Practice Research Datalink

PURPOSE

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) may be treated with surgical mesh devices; evidence of their long-term complications is lacking.

PATIENTS AND METHODS

Rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids were estimated in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database.

RESULTS

There were 220,544 women eligible for inclusion; 74% (n = 162,687) had SUI, 37% (n = 82,123) had POP, and 11% (n = 24,266) had both. Women undergoing mesh surgery for SUI or POP had about 1.1 times higher rates of antibiotic use. Women with no previous history of the outcome, who underwent mesh surgery had 2.43 (95% CI 2.19-2.70) and 1.47 (95% CI 1.19-1.81) times higher rates of depression, anxiety, or self-harm, 1.88 (95% CI 1.50-2.36) and 1.64 (95% CI 1.02-2.63) times higher rates of sexual dysfunction and 1.40 (95% CI 1.26-1.56) and 1.23 (95% CI 1.01-1.49) times higher opioid use for SUI and POP, respectively. Women with a history of depression, anxiety and self-harm had 0.3 times lower rates of these outcomes with SUI or POP mesh surgery (HR for SUI 0.70 (95% CI 0.67-0.73), HR for POP 0.72 (95% CI 0.65-0.79)). Women with a history of opioid use who had POP mesh surgery had about 0.09 times lower rates (HR 0.91 (95% CI 0.86-0.96)) of prescriptions. Negative control outcome analyses showed no evidence of an association between asthma consultations and mesh surgery in women with POP, but the rate was 0.09 times lower (HR 0.91 (95% CI 0.87-0.94)) in women with SUI mesh surgery, suggesting that study results are subject to some residual confounding.

CONCLUSION

Mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. Although our results suggest an influence of residual confounding, careful consideration of the benefits and risk of mesh surgery for women with SUI or POP on an individual basis is required.

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh: experiences of 93 cases

INTRODUCTION AND HYPOTHESIS

To demonstrate the outcomes of pelvic reconstruction using Y-shaped mesh in patients with multiple-compartment pelvic organ prolapse via transvaginal single-port laparoscopy.

METHODS

We conducted a retrospective case series study. Patients diagnosed with severe multiple-compartment prolapse were enrolled between July 1, 2017, and March 31, 2020. Patients underwent transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh. Baseline data and perioperative results were collected. Patients were followed up with the POP-Q score, Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12). T-test was used for statistical analysis.

RESULTS

Operations were successful in all 93 patients without conversion or serious complications. Mean operative time was 132.70 ± 28.02 min and estimated blood loss was 110.65 ± 56.31 ml. VAS pain score was 2.91 ± 1.16 and cosmetic score was 9.20 ± 0.60. During 1-33 months of follow-up, no recurrence or mesh exposure was observed. Five patients suffered from de novo SUI, six had constipation, two had dyspareunia, and one had persistent pelvic pain. The pre- and postoperative Aa point was +2.13 ± 1.23 vs. -2.91 ± 0.28 (P < 0.05), C point was 2.63 ± 2.41 vs. -6.86 ± 0.69 (P < 0.05), and Ap point was -0.26 ± 1.79 vs. -2.97 ± 0.16 (P < 0.05). The PFDI-20 score was 76.81 ± 32.06 vs. 18.18 ± 20.25 (P < 0.05), while the PISQ-12 score was 34.30 ± 4.17 vs. 37.20 ± 2.60 (P < 0.05), which suggested significant improvements in both physical prolapse and quality of life after surgery.

CONCLUSION

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh is a feasible, effective and safe treatment option for severe multiple-compartment prolapse. Patients may benefit from its mild pain level and good cosmetic effect as well as only minor mesh-related complications.