Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.     

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

Introduction and hypothesis  

The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.     

Abdominal mesh sacrocolpopexy for recurrent triple‐compartment pelvic organ prolapse

OBJECTIVE

To report the short‐ and intermediate‐ term outcome of safety and efficacy after abdominal‐mesh sacrocolpopexy (MSC) for recurrent anterior, posterior and vault (‘triple‐compartment’) pelvic organ prolapse (POP).

PATIENTS AND METHODS

In a database review we identified non‐neurogenic women who had MSC for recurrent triple‐compartment POP and with a ≥6‐month cystographic follow‐up. The preoperative evaluation included a history, physical examination, Urogenital Distress Inventory (UDI‐6) and visual analogue quality‐of‐life (QoL) questionnaires, urodynamic studies, and a standing lateral voiding cysto‐urethrogram (VCUG) with rest‐strain views. All surgery as performed by the same surgeon, using polypropylene (Marlex) mesh. Perioperative data, the VCUG at 6 months, and interval pelvic examinations were recorded.

RESULTS

Between 2000 and 2006, 29 postmenopausal women (Caucasian, mean age 64 years, sd 11) underwent MSC. The mean (sd , range) operative duration was 228 (75, 170–340) min, the estimated blood loss 150 (100) mL and the inpatient stay 3 (1) days. At a mean (sd ) follow‐up of 23 (16) months, the physical examination showed no evidence of POP of grade ≥2, with mean POP‐Quantification scores of ?2.8 (0.4), ?2.9 (0.4) and ?9.3 (0.8) for points A_a, A_p and C, respectively. Two patients (8%) had evidence of grade ≥2 cystocele at the 6‐month VCUG. After MSC, four of the six UDI and the QoL scores were significantly lower at the last follow‐up than at baseline, with no change in sexual or defecatory function.

CONCLUSIONS

The objective and subjective improvement at the short and intermediate follow‐up after MSC suggest that this is a safe and effective treatment for recurrent triple‐compartment POP.     

Postoperative voiding function in patients undergoing tension-free vaginal mesh procedure for pelvic organ prolapse

Introduction and hypothesis  

We compared pre- and postoperative voiding function in patients with POP and assessed the efficacy of urodynamic studies in these cases.     

Tension‐free vaginal mesh procedure for pelvic organ prolapse: A single‐center experience of 310 cases with 1‐year follow up

Objective: To prospectively evaluate the efficacy of a tension‐free vaginal mesh (TVM) procedure for pelvic organ prolapse (POP). Methods: Between December 2005 and April 2008, 310 female patients (mean age 67.2 years, range 42–84) with POP underwent TVM procedures at our institute. Fifty‐six individuals were qualified as stage 2 according to the POP quantification system and 162 and 92 were stage 3 and 4, respectively. One hundred ninety‐one patients underwent anterior TVM, and seven underwent posterior TVM. One hundred twelve cases underwent both anterior and posterior TVM procedures. Each patient was systematically assessed at 1, 3, 6 and 12 months after surgery. Quality of life (QOL) was also assessed by using the Short Form‐36 and the prolapse‐QOL questionnaires. Results: Perioperative complications were the following: five bladder injuries (1.6%), no rectal injuries and three hemorrhages greater than 400 mL (1.0%). The anatomical cure rate (% stage 0 cases) at 3, 6 and 12 months after surgery were 94.1%, 93.5%, and 92.3%, respectively. Short Form‐36 and prolapse‐QOL parameters were significantly improved, and maintained during the follow‐up period. Postoperative complications were the following: five pelvic hematomas (1.6%), one wound infection (0.3%), 10 vaginal mesh extrusions (3.2%), and three cases of pelvic pain (1.0%). Complications concerning lower urinary tract function were: eight cases of postoperative stress urinary incontinence (2.6%), three cases of transient urinary retention (1.0%), and two cases of de novo overactive bladder (0.6%). Conclusions: The TVM procedure provides a good outcome at 1 year with a low incidence of surgical complications and recurrence. Further evaluation with a longer follow up is needed.     

Nerve preservation in tension-free vaginal mesh procedures for pelvic organ prolapse: a cadaveric study using fresh and fixed cadavers

The aims of this study were, using fixed and fresh cadavers, to clarify how closely the pelvic splanchnic nerve, levator ani nerve (LAN), and sacrospinous ligament (SSL) are located and to examine how to avoid nerve injury during the posterior tension-free vaginal mesh procedure (TVMP), in which mesh is applied through the SSL. Macroscopic dissection of fixed cadavers demonstrated that the LAN crossed the inside of the SSL at a point 0–18 mm medial to the ischial spine and entered the muscle at a point 12–26 mm inferior to the ischial spine and 40–55 mm anterolateral to the coccyx. Dissection after TVMP of fresh cadavers revealed that the point of penetration of mesh through the SSL was close to the LAN. To preserve the LAN, penetration of the SSL should be within 5 mm of the lower margin at a point 20–25 mm medial to the ischial spine.     

Informed surgical consent for a mesh/graft-augmented vaginal repair of pelvic organ prolapse

Introduction and hypothesis

Complex issues surround informed surgical consent for pelvic reconstructive surgery.

Methods

Vaginally placed mesh/grafts are used with the intent to increase durability of the repair but potentially introduce unique complications, offering new challenges in informed surgical consent counseling.

Results

Informed consent is a process that takes place throughout the entire consultation with the patient. A written document often accompanies that process. This paper outlines necessary components of informed surgical consent and the theory behind each component.

Conclusions

We explore elements that should be included in the consent process with regard to expected benefits, alternatives, and material risks that are specific to the use of a mesh/graft-augmented vaginal repair of prolapse. Included is an appendix that may serve as a template for the creation of a surgeon’s own written informed consent document.

     

Sexual function in women following transvaginal mesh procedures for the treatment of pelvic organ prolapse

Introduction and hypothesis

Synthetic mesh kits recently adopted in pelvic reconstructive surgeries have achieved great surgical efficacy, but the effects of transvaginal synthetic mesh procedures on women’s sexual function are still controversial. This study was conducted to demonstrate sexual function in women before and after surgery with transvaginal mesh (TVM) repair for pelvic organ prolapse (POP).

Methods

A total of 93 sexually active women scheduled for correcting POP with synthetic mesh kits were recruited. In addition to urogynecological history, pelvic examination by the Pelvic Organ Prolapse Quantification system, and urodynamic testing, consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function before and after surgery.

Results

At the 3-month urodynamic studies, among the 25 patients with coexistent urodynamic stress incontinence (USI) who had undergone a concomitant transobturator suburethral tape procedure (TOT), 1 (4 %) had persistent USI; 8 of 68 (11.8 %) patients with a negative pessary test developed postoperative USI. Six-month prolapse recurrence rates following TVM alone and TVM with concomitant TOT were 9 and 12 %, respectively. The total PISQ-12 score after surgery showed worse results in the TVM alone group but not in the TVM with concomitant TOT group. The individual scores of PISQ-12 after surgery demonstrated prolapse-related items improved in both TVM groups; sexual function worsened in dyspareunia and behavior domains.

Conclusions

Our data revealed that transvaginal synthetic mesh procedures for the treatment of POP generated favorable clinical outcomes, but situations might worsen in dyspareunia and behavior domains, thereby invoking a negative emotional reaction during intercourse after surgery.     

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.     

Vaginal placement of synthetic mesh for pelvic organ prolapse

Since 2004, use of synthetic mesh has increased in vaginal surgery for the treatment of pelvic organ prolapse. However, concerns exist about the safety and efficacy of transvaginally placed mesh. Based on the currently available limited data, although many patients undergoing mesh-augmented vaginal repairs heal well without problems, there seems to be a small but significant group of patients who experience permanent and life-altering sequelae, including pain and dyspareunia, from the use of vaginal mesh. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society provide background information on the use of vaginally placed mesh for the treatment of pelvic organ prolapse and offer recommendations for practice.     

Laparoscopic sacrocolpopexy versus transvaginal mesh for recurrent pelvic organ prolapse

Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon’s audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.     

Factors that affect outcomes of prolapse repair using single‐incision vaginal mesh procedures

Aims

Single‐incision vaginal mesh (SIVM) procedures for pelvic organ prolapse (POP) differed in mesh fabrication and implantation that may affect treatment outcomes. We aim to evaluate and compare the safety and effectiveness of two SIVM procedures, and explore factors that may have associations with surgical effectiveness.

Methods

Our data of using two SIVM procedures for a total (anterior and posterior) vaginal mesh repair were studied. Patients who had ≧stage 2 POP and underwent either Elevate (n = 85) using anchored, lightweight meshes or Prosima procedures (n = 95) using non‐anchored, original meshes were assessed. A detailed comparison of 1 year outcomes was made.

Results

Of the 180 patients, 172 (95.6%) attended the 1‐year follow‐up. Demographic data were similar between groups except a higher average age (64.5 vs 60.4, P = 0.001) was noted in the Elevate (n = 84) group compared to the Prosima (n = 88) group. Surgical results were also similar except a significantly higher objective cure (POP stage ≦1) rate (89.3% vs 78.4%, P = 0.042) was noted in the Elevate group. The safety profile favored Elevate with a lower, but not statistically significant, rate (4.7% vs 12.5%, P = 0.106) of vaginal mesh exposure. After a statistical analysis, we found anatomic recurrence (POP stage ≧2) after the SIVM procedures had strong (P < 0.05) associations with “early surgical cases,” “Prosima procedure,” “advanced cystocele (Ba > +3 cm),” and “prior prolapse repair,” respectively.

Conclusions

Beyond a learning curve, Elevate performed better than Prosima in POP repair regarding surgical effectiveness. Meanwhile, several predisposing factors that may affect recurrence after SIVM procedures were found.     

Laparoscopic removal of intravesical mesh following pelvic organ prolapse mesh surgery

With the increasing popularity of mesh in prolapse surgery, complications such as intravesical mesh will arise more frequently. In three cases intravesical mesh was identified in the trigone of the bladder following laparoscopic mesh hysteropexy, open sacral colpopexy, and transvaginal mesh repair and presented 9 months to 7 years later with a variety of symptoms including recurrent urinary tract infections, suprapubic pain, and constant urinary leakage. Each underwent uncomplicated laparoscopic transvesical removal of intravesical mesh. Intravesical mesh can present years following index prolapse surgery and can develop despite the bladder integrity being documented as being intact at the initial surgery. The laparoscopic approach to the removal of intravesical mesh is feasible, minimally invasive, and a precise approach to this challenging complication.