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Management of Mesh Complications after SUI and POP Repair: Review and Analysis of the Current Literature.

Barski D, Deng DY - Biomed Res Int (2015)

Bottom Line: Prior to recurrent surgeries, a careful examination and planning for the operation strategy are crucial.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Lukas Hospital, Preussenstrasse 84, 41464 Neuss, Germany.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus

Subjective cure rate after MUS-mesh excision (mean), P < 0.05.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4418012&req=5

fig3: Subjective cure rate after MUS-mesh excision (mean), P < 0.05.

Mentions: A comprehensive diagnosis of symptoms and localization of erosion by cystoscopy, vaginal examination, imaging and urodynamics, education of patients on possible irreversible damage, and careful planning of the operation steps are required prior to revision surgery. A careful clinical examination and determination of the pain location by trigger points are excellent markers for planning of the site and extent of mesh resection [20, 33]. However, a standardized surgical procedure and access do not exist up to date. The analysis of the available studies showed a similar subjective cure rate of 79–100% for different techniques (Figure 3). The rate of reoperations was higher if an endoscopic or transvaginal access were chosen [18, 19, 21, 22, 24, 30]. However, the hospital stay, operation time, and postoperative pain were higher in the case of laparoscopic mesh excision [30]. Generally, a vaginal access with partial or complete resection of the infected foreign material is favored in most trials (88% of the analysed studies). Non-type 1 alloplastic materials according to Amid classification (e.g., polytetrafluoroethylene and Gore-Tex) have to be removed completely in case of erosion or infection in order to achieve symptom relief [34]. A complete mesh excision can be very difficult especially for abdominal access. Complications such as bleeding, fistula, neuropathies, and prolapse recurrence are frequent [20]. Different transvaginal techniques like sling loosening, mesh incision, and partial or complete excision were described in included studies but no clear strategy or algorithm could be found (Table 1). Costantini and colleagues propose the following intraoperative management of mesh exposure: closure of the vaginal defect with double-layer suture to avoid a direct mesh contact with the mucous membranes, flush with antibiotic solution, no stitching of the full thickness of the vaginal wall, atraumatic preparation, use of nonwoven, nonabsorbable suture and polypropylene meshes, avoidance of concomitant hysterectomy, and long-term follow-up after the revision [20]. Similar vaginal techniques with optional excision of the alloplastic material and two-layer closure of a vesicovaginal fistula are described by other authors [22]. The German group from Mainz University reported on the urogynecological management of complications based on 259 patients after implantation of MUS [25]. In the case of de novo OAB, the symptoms improved only after the resection of the portion of the sling which was in contact with the urethra. The wrong position of the sling could be detected by pelvic floor sonography (PFS). PFS is an important tool to assess the tape position, form, and distance from urethra. The reasons for the complications and sling failure can be identified and corrected. The ultrasonography evaluation of a well-positioned sling provides certainty that a success of conservative therapy can be expected. In case of a dystopic position of the sling, the first step is to evaluate the sling location and to decide whether or not the band can be saved [34]. The removal of the foreign material was more difficult if the initial operation has been long ago. Particularly difficult and traumatic for the pelvic floor were the excisions of transobturator tapes [25]. Infections of the alloplastic material in the obturator fossa are especially dangerous for the development of abscesses or necrotising fasciitis and require careful debridement and follow-up. If a significant erosion of the mesh was diagnosed, partial vaginal material removal has been usually performed. In case of vaginal mesh exposure (small erosions under 1 cm without infection), the defect could be closed by a suture. In case of mesh shrinkage, a resection of the fibrotic band in the paravaginal sulci was proposed. In some cases, infection of TOT required extensive debridement with opening of the deep tissues of the groin and adductor compartment, removal of the complete tape, antibiotics, and sometimes hyperbaric oxygen therapy [15]. Agnew and colleagues reviewed 63 women with voiding dysfunction (>150 mL residual volume) after MUS (67% TVT). Three different surgical procedures were analysed (simple sling division, partial resection, and concomitant SUI procedure). Taking into account the results of the findings (Table 1), the authors changed their strategy to divide synthetic midurethral slings lateral to the urethra and then carefully perform cystourethroscopy to ensure that no urinary tract injury has occurred [18].


Management of Mesh Complications after SUI and POP Repair: Review and Analysis of the Current Literature.

Barski D, Deng DY - Biomed Res Int (2015)

Subjective cure rate after MUS-mesh excision (mean), P < 0.05.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4418012&req=5

fig3: Subjective cure rate after MUS-mesh excision (mean), P < 0.05.
Mentions: A comprehensive diagnosis of symptoms and localization of erosion by cystoscopy, vaginal examination, imaging and urodynamics, education of patients on possible irreversible damage, and careful planning of the operation steps are required prior to revision surgery. A careful clinical examination and determination of the pain location by trigger points are excellent markers for planning of the site and extent of mesh resection [20, 33]. However, a standardized surgical procedure and access do not exist up to date. The analysis of the available studies showed a similar subjective cure rate of 79–100% for different techniques (Figure 3). The rate of reoperations was higher if an endoscopic or transvaginal access were chosen [18, 19, 21, 22, 24, 30]. However, the hospital stay, operation time, and postoperative pain were higher in the case of laparoscopic mesh excision [30]. Generally, a vaginal access with partial or complete resection of the infected foreign material is favored in most trials (88% of the analysed studies). Non-type 1 alloplastic materials according to Amid classification (e.g., polytetrafluoroethylene and Gore-Tex) have to be removed completely in case of erosion or infection in order to achieve symptom relief [34]. A complete mesh excision can be very difficult especially for abdominal access. Complications such as bleeding, fistula, neuropathies, and prolapse recurrence are frequent [20]. Different transvaginal techniques like sling loosening, mesh incision, and partial or complete excision were described in included studies but no clear strategy or algorithm could be found (Table 1). Costantini and colleagues propose the following intraoperative management of mesh exposure: closure of the vaginal defect with double-layer suture to avoid a direct mesh contact with the mucous membranes, flush with antibiotic solution, no stitching of the full thickness of the vaginal wall, atraumatic preparation, use of nonwoven, nonabsorbable suture and polypropylene meshes, avoidance of concomitant hysterectomy, and long-term follow-up after the revision [20]. Similar vaginal techniques with optional excision of the alloplastic material and two-layer closure of a vesicovaginal fistula are described by other authors [22]. The German group from Mainz University reported on the urogynecological management of complications based on 259 patients after implantation of MUS [25]. In the case of de novo OAB, the symptoms improved only after the resection of the portion of the sling which was in contact with the urethra. The wrong position of the sling could be detected by pelvic floor sonography (PFS). PFS is an important tool to assess the tape position, form, and distance from urethra. The reasons for the complications and sling failure can be identified and corrected. The ultrasonography evaluation of a well-positioned sling provides certainty that a success of conservative therapy can be expected. In case of a dystopic position of the sling, the first step is to evaluate the sling location and to decide whether or not the band can be saved [34]. The removal of the foreign material was more difficult if the initial operation has been long ago. Particularly difficult and traumatic for the pelvic floor were the excisions of transobturator tapes [25]. Infections of the alloplastic material in the obturator fossa are especially dangerous for the development of abscesses or necrotising fasciitis and require careful debridement and follow-up. If a significant erosion of the mesh was diagnosed, partial vaginal material removal has been usually performed. In case of vaginal mesh exposure (small erosions under 1 cm without infection), the defect could be closed by a suture. In case of mesh shrinkage, a resection of the fibrotic band in the paravaginal sulci was proposed. In some cases, infection of TOT required extensive debridement with opening of the deep tissues of the groin and adductor compartment, removal of the complete tape, antibiotics, and sometimes hyperbaric oxygen therapy [15]. Agnew and colleagues reviewed 63 women with voiding dysfunction (>150 mL residual volume) after MUS (67% TVT). Three different surgical procedures were analysed (simple sling division, partial resection, and concomitant SUI procedure). Taking into account the results of the findings (Table 1), the authors changed their strategy to divide synthetic midurethral slings lateral to the urethra and then carefully perform cystourethroscopy to ensure that no urinary tract injury has occurred [18].

Bottom Line: Prior to recurrent surgeries, a careful examination and planning for the operation strategy are crucial.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Lukas Hospital, Preussenstrasse 84, 41464 Neuss, Germany.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus