Functional: Mesh Complications

See 2019 CUA/AUA Mesh Statement

Pelvic Reconstructive Surgery

• The current standard of surgical repair for the treatment of prolapse of the pelvic organs is a mesh suspension of the prolapse to the sacral promontory (sacrocolpopexy).
• Mesh was adopted to augment native tissue repair to improve objective outcomes
  • The most widely used products are made of polypropylene because this material has demonstrated significantly fewer morbid complications compared with prior material
    • Polypropylene is categorized as a type I macroporous monofilament mesh

Complications of Mesh in Pelvic Reconstructive Surgery

• May be due to synthetic material, host response, surgical factors, or a process not yet identified
• Occur in 10% of patients
  • Are usually minimially morbid but some cannot be completely reversed.
  • Long-term complications may manifest months or years after insertion.
• The Committee on Gynecologic Practice recommendeds counseling patients regarding the risks of:
  1. Mesh exposure (range 1-19%):
  2. Buttock, groin, or pelvic pain (range 0-18%)
  3. De novo dyspareunia (range 2-28%)
  4. Reoperation (range 1-22%)

Diagnosis and Evaluation of Mesh Complications

• History and Physical Exam
  • Review medical records of mesh procedure
  • Neurologic, musculoskeletal, and organ injury range in severity and time of presentation
  • Mesh penetration into the urethra or bladder typically manifests with
    • Hematuria
    • Urinary tract infections
    • Pain
      • Retropubic sling arms may damage the ilioinguinal nerve (L1) and the genital branches of the genitofemoral nerve causing sharp localized pain, whereas obturator arms may damage the posterior branches of the femorocutaneous, posterior cutaneous (L2-S3), pudendal, perineal, inferior anal, or obturator nerves (L5-S1)
  • Symptoms of vaginal mesh exposure include:
    • Bleeding
    • Infection
    • Fistula
    • Pain
    • Dyspareunia
    • Organ perforation
    • Obstruction
    • Dysfunction
• Imaging
  • Options
    • Voiding cystourethrogram for urinary obstruction
    • CT scan for abdominal abscess.
    • MRI for osteitis or osteomyelitis.
    • Translabial ultrasound for mesh location and size

Management of Mesh Complications

• Expectant Management and Counseling
  • Mild complications such as voiding dysfunction or discomfort often resolve spontaneously with minimal intervention, and careful monitoring of these patients is recommended.
    • A patient with asymptomatic mesh exposure without pain or pelvic organ dysfunction is an example of an appropriate candidate for expectant management.
• When complications persist past the perioperative period or do not resolve with conservative management, they may require medication or intervention. Such complications include:
  1. Prolonged voiding dysfunction
  2. Urinary obstruction
  3. Vaginal pain or dyspareunia
  4. Erosion into an organ or exposure through the vaginal wall
  5. Defecatory dysfunction
  • Medical Management
    • If an infectious component of mesh exposure is suspected, treatment with antibiotics is reasonable
    • If tissue atrophy is suspected, initiating vaginal estrogen can combat this process
  • Surgical
    • Removal of mesh in cases of severe refractory pain may improve symptoms in most patients
    • Risk of anterior prolapse recurrence after mesh removal is 20%.
    • Risk of incontinence after sling removal ranges from 30% to 50%.
    • Patients with persistent urinary retention may be offered surgical urethrolysis

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 85