Vaginal mucosal flap as a sling preservation for the treatment of vaginal exposure of mesh

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.

What to do after a mid-urethral sling fails

PURPOSE OF REVIEW

After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.

RECENT FINDINGS

Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.

SUMMARY

MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

The role of bladder neck suspension in the era of mid-urethral sling surgery

INTRODUCTION

Mid-urethral slings are currently considered to be the gold standard for the surgical treatment of stress urinary incontinence, replacing bladder neck suspension techniques which previously occupied this position. In recent years, however, there have been concerns with regard to the use of synthetic material in vaginal surgery.

METHODS

We performed a review of the literature to discuss the role of bladder neck suspension techniques in the current clinical setting.

CONCLUSIONS

Bladder neck suspension techniques consist of vaginal techniques, needle suspension techniques and retropubic techniques. The latter two techniques have been proven to offer durable outcomes for stress urinary incontinence. As compared to autologous slings, the long-term success rates may be considered inferior, but so is the rate of complication, resulting in higher patient satisfaction. Bladder neck suspension techniques may have a role in treating recurrent and/or persisting stress urinary incontinence after (failed) sling surgery and remain of particular interest in patients with stress urinary incontinence when performing concomitant surgery, for example for prolapse.

Urethral erosion and perineal cellulitis after midurethral sling procedure

Midurethral tension-free sling procedure has become one of the most popular techniques for the treatment of stress urinary incontinence. As the time elapsed, however, complications associated with a synthetic tape have been reported to occur. Recently, we experienced a rare case of urethral erosion with perineal cellulitis at anterior wall of vagina after midurethral sling procedure. So our experience was presented with a review of literature.

[Reconstructive treatment of female urethral estenosis secondary to erosion by suburethral tape]

INTRODUCTION

Female urethral stricture secondary to erosión by suburethral sling is an unfrequent problem of difficult solution. Ventral vaginal rotation flaps or buccal mucosa dorsal grafts are not useful because this type of stricture is very proximal (close to the bladder neck) and the vagina is thinned. We present our experience to manage this problem using excision of disease urethral tract, associated to bladder mucosa flap and vaginal sling using transverse vaginal flap to repair the weakened vaginal wall.

MATERIAL AND METHODS

Three females with urethral stricture secondary to urethral erosion of their sling were treated with a technique of combined urethroplasty with bladder flap and vaginal reinforcement with pediculated vaginal flap transferred in a mini-sling fashion. Two of the patients suffered chronic urinary retention and preoperative placement of urethral catheter was not possible. The patients were evaluated 12, 36 and 55 months after surgery, respectively.

RESULTS

Surgery was performed without complications. Results were satisfactory in all the patients, reaching good micturition postoperative caliber and being without incontinence at follow-up.

CONCLUSION

Patients with suburethral erosion by a synthetic sling and secondary severe urethral stricture need total extirpation of the mesh and complete reconstruction of the urethro-vaginal septum. Tension-free urethral suture and use of vaginal sling with the technique here described are two useful technical tips for this problem.