Assessment and initial management of mesh complications

Synthetic polypropylene mesh have been used in the surgical management of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) since 1990's. However, following patients'-led campaign with concerns regarding the complications associated with mesh, their use in surgical management of SUI and/or POP has been controversial. Complications associated with these mesh implants include chronic pain, vaginal mesh exposure, perforation into organs, infections and sinus tract formation. In April, 2019, the NICE guideline (NG123) provided an evidence review for management of mesh complications. Following Independent Medicine and Medical Devices Safety Review (IMMDS) publication in 2020, a network of specialized complex mesh centres across the UK have been set up. All patients with mesh-related complications should receive specialist multidisciplinary care in these centres. In this review, we outline the assessment and initial management of patients who present with mesh-related complications. Assessment and management options should be tailored per individual cases. Assessment includes clinical assessment and investigations including radiological imaging. All management options including no treatment, conservative, medical and surgical treatment, including minimally invasive treatment with the pros and cons of every option should be offered and patient should be actively involved in their decision making in a “shared-decision making” manner.     

经阴道植入网片手术与疼痛

经阴道植入网片（tranvaginal mesh,TVM）手术已广泛用于盆腔器官脱垂（pelvic organ prolapse,POP）的修复治疗,复发率较自体组织修复术有所降低,但由于网片相关的独特并发症,美国食品药品监督管理局（FDA）曾多次通告并于2019年4月宣布禁止TVM在美国销售。疼痛作为TVM术后的主要并发症之一,严重影响患者生活质量。文章重点论述TVM术后相关疼痛的类型、原因、可能的机制及处理原则,并展望TVM的未来发展应用。     

经阴道植入网片手术与疼痛

经阴道植入网片（tranvaginal mesh，TVM）手术已广泛用于盆腔器官脱垂（pelvic organ prolapse，POP）的修复治疗，复发率较自体组织修复术有所降低，但由于网片相关的独特并发症，美国食品药品监督管理局（FDA）曾多次通告并于2019年4月宣布禁止TVM在美国销售。疼痛作为TVM术后的主要并发症之一，严重影响患者生活质量。文章重点论述TVM术后相关疼痛的类型、原因、可能的机制及处理原则，并展望TVM的未来发展应用。     

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.     

Fetal ovarian cysts: incidence, diagnosis and management

Greater numbers of fetal ovarian cysts are being diagnosed due to improved antenatal imaging. These numbers correspond to data from autopsy studies showing approximately 30% of neonates to have ovarian cysts. Fetal ovarian cysts pose a risk of acute and long-term complications. These risks must be weighed against the probability of cyst regression. The de- The decision to cision to intervene must be based on cyst based on cyst size, ultracharacteristic sound characteristics and clinical symptoms. Treatment options include conservative management, antenatal or neonatal cyst aspiration, laparoscopic cystectomy and laparotomy. Diagnosis is important, given the possible complications and the current management options. Criteria for management have been established at several centers; however, a controversy over conservative versus surgical therapy remains.     

Technique and complications of reconstruction of the pelvic floor with polyglactin mesh

A polyglactin mesh sling was used to reconstruct the pelvis in eight patients after colorectal or urologic resections in preparation for postoperative radiation therapy. There were three perioperative complications--a pelvic abscess requiring percutaneous drainage, a wound dehiscence and a herniation of the small intestine between the pelvic sidewall and mesh requiring small intestinal resection. There were two delayed complications, both partial small intestinal obstructions. One occurred just after the conclusion of radiation treatment and the other occurred five months after the conclusion of radiation therapy. Both obstructions responded to conservative management. None of the common acute radiation effects occurred during radiotherapy. One patient with delayed partial small intestinal obstruction had possible late radiation effects. The median follow-up period after radiation therapy was 12.5 months. Despite the complications described in this report, the use of a polyglactin mesh sling as an adjunct to resection of carcinoma of the pelvis has merit and should be studied further.     

Management of complications of mesh surgery

Polypropylene mesh (PPM) has been used in abdominal sacrocoplopexies since the 1990's however following a patient led campaign controversy surrounds its use incontinence procedures, midurethral slings (MUS) and vaginal mesh prolapse repairs. The complication rates following mesh surgery may be as high as 10%. NHS England paused the vaginal insertion of polypropylene mesh in July 2018 pending a review by Baroness Cumberledge. This review will outline the assessment and basic management of complications of polypropylene mesh. This is a relatively new area of urogynaecological practice which non-specialist obstetric and gynaecology clinicians and GPs need to be aware of. Symptoms which could be due to mesh complications are vaginal discharge or bleeding, recurrent urinary tract infection, haematuria, dyspareunia and pelvic pain. Women presenting with any of the above symptoms should be asked if they have had previous surgery for stress incontinence or prolapse. The women may not recall having mesh inserted and may use different terms “sling” “net” or “tape”. They should be examined to both look and feel for PPM. Mesh complications should be managed by the designated mesh centres which are listed on the BAUS and BSUG websites. All mesh complications should be reported to the Medicines & Healthcare products Regulatory Agency (MHRA) by the yellow card system. All mesh complications requiring further surgical intervention should be recorded on the British Society of Urogynaecology (BSUG) national database.     

Erosion of mesh after repair of rectocele

Genital prolapse is a common problem in women. Surgical repair is one of the management options. Traditional repair consists of midline plication of endopelvic fascia to reduce the prolapse and create support. A mesh has also been used to augment and repair such defects in the pelvic floor. Data on the efficacy and safety of mesh repair for genital prolapse are limited in literature. We present a rare case of mesh erosion 18 years after a rectocele repair.     

Management of pregnancy in a Jehovah's Witness

In the successful management of a pregnant Jehovah's Witness, many issues must be addressed beyond those normally required for routine prenatal care. The clinician who undertakes such care should be well versed in the potential complications related to blood refusal, the antepartum management of anemia, and the intrapartum management of obstetric hemorrhage. Furthermore, these patients should be delivered in a tertiary care center because this increases their options for obtaining alternative management of hemorrhage. A woman who is well informed about her options can then decide exactly what she wants done in the event of a life-threatening obstetrical hemorrhage.     

Complications of polypropylene mesh in prolapse surgery

Traditional surgical repair for pelvic organ prolapse may be associated with a high recurrence rate. Mesh is being used increasingly to replace damaged endo-pelvic fascia, in an attempt to reduce recurrence. Polypropylene mesh is currently preferred over biological and synthetic absorbable meshes, aiming to reduce failure. Mesh may be placed abdominally (sacro-colpopexy) or vaginally to correct prolapse. Whilst sacro-colpopexy is a well-established procedure for the correction of vault prolapse, there is a lack of strong evidence of safety and efficacy for vaginal placement of mesh. The majority of reported complications related to mesh are minor though occasionally severe complications arise. The management of complications can be difficult, particularly when experience and evidence are lacking. Guidelines suggest that vaginal mesh repairs should only be performed by surgeons with training and expertise, with special arrangements for clinical governance, consent, audit and research.     

Severe mesh complications following intravaginal slingplasty

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended.     

Management of preeclampsia.

Prompt hospitalization is the optimum management of all patients with preeclampsia. Expectant management is possible in most patients remote from term. The success rate of expectant management will depend on both fetal gestational age and the state to which the disease has progressed at the time of hospitalization. Maternal and perinatal complications are increased significantly in patients with severe preeclampsia and in those with the HELLP syndrome. Thus, these patients should be managed only at tertiary care centers.     

Difficulties associated with removal of mesh eroding into vagina following abdominal sacrocolpopexy: a case report

This case report describes the clinical case of a patient presenting complications during removal of mesh eroding through the lower one third of the posterior vaginal wall following abdominal sacrocolpopexy. Although excellent results have been reported with abdominal sacrocolpopexy for treatment of vaginal vault prolapse, minimizing complications and their correction remains a challenge. In this case, only 3/4 of the mesh was removed vaginally and was complicated by small bowel perforation due to adhesions. The remaining mesh was removed by careful dissection from the sacral base as the risk of infection in the mesh left behind is increased. Successful management eventually requires complete removal of the mesh at laparotomy. The surgery should be performed by experienced pelvic surgeons able to resolve intraoperative complications. Although serious complications are rare, patients should nonetheless be counselled about the risk of massive bleeding, bowel perforation, infection and rectovaginal fistula formation.     

The open management of the septic abdomen

The mortality rate of severe intra-abdominal infections is still very high. The open management of the abdomen is a method of treatment which has gained popularity over the past few years. Its advantages include a better drainage of the peritoneal cavity, a greater protection of the parietes, an improved perfusion of the abdominal viscera and a decrease in postoperative pulmonary complications. It is indicated in patients with severe intra-abdominal sepsis, especially when multiple re-explorations of the abdomen are likely. A variety of techniques, including the use of Marlex mesh have been devised to contend with possible complications: spontaneous fistulas, exogenous bacterial contamination, evisceration and massive fluid losses. The open method of management has not made the treatment of septic abdomen much easier; it requires intensive care support and repeated assessment of the peritoneal cavity. The closure of the abdomen is a problem which must be addressed when the sepsis has subsided. The value of this technique is still difficult to assess in the absence of controlled randomized trials.     

Autologous Fascial Slings for Surgical Management of Stress Urinary Incontinence: A Come Back

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly’s plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it’s routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.     

应用网片盆底重建手术术后感染的防治

与传统治疗女性盆底功能障碍性疾病的术式相比,经阴道网片置入术可以明显降低复发率。但网片相关的并发症也日益凸显。文章针对与网片相关的感染的发病率、临床表现、高危因素、预防与诊治进行了详细的阐述。     

Angiographic and interventional options in obstetric and gynecologic emergencies

This article describes the role of angiographic and interventional techniques in the management of obstetrical and gynecologic hemorrhage. The complementary role of endovascular therapy is discussed and a review of management options for both peripartum hemorrhage and gynecologic hemorrhage is presented. The article describes special management options involving angiographic techniques for placentation abnormalities and arteriovenous malformations, and discusses a limited role for embolization in the management of ectopic pregnancies. The authors also present the outcomes of embolotherapy, associated complications, and implications for future fertility. This article describes the role of embolotherapy as it has evolved over the last three decades and clarifies the endovascular management options available to patients.     

Early pregnancy failure--current management concepts

Approximately one in four women will experience a miscarriage during her lifetime. For more than 50 years, the standard management of early pregnancy failure has been a dilatation and curettage (D & C). Typically, the procedure is performed in an operating room, which significantly increases cost. There is little objective information in the modem literature to prove that a D & C for all patients will lower morbidity or improve emotional well being. Treatment options include expectant management, D & C in an outpatient setting, and medical management with misoprostol (not approved by the U.S. Food and Drug Administration for treatment of early pregnancy failure). The medical literature supports that expectant management may result in more complications, including the need for "emergent" curettage, if clinicians do not understand the true normal course of expectant management. In general, women prefer some form of active management. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration. Vaginal misoprostol will cause expulsion in 80% to 90% of women up to 13 weeks' uterine size or gestation, including patients who have a gestational sac present. However, these data come from only three trials involving a total of 42 subjects treated with vaginal misoprostol, and another study of 42 women who received vaginal misoprostol for "missed abortion" before a scheduled D & C. There is a significant lack of information from large-scale studies about when treatment is necessary and the relative efficacy, rates of side effects, and acceptability of these various treatment options for early pregnancy failure.     

Management of premature rupture of membranes

The management of patients with PROM, regardless of gestational age, remains controversial. Generally, when patients are in labor, have infection, or there is irreversible fetal distress, there are few options other than delivery. For those not in labor, especially in premature gestational ages, the complexities of the many combinations of decisions to be made regarding the best methods for evaluating patients, prolonging gestation, reducing complications of prematurity, and choosing the timing and route of delivery make studying and solving the problem of the best option for management difficult at best. The administration of corticosteroids and broad-spectrum antibiotics of those patients in the very early premature gestational age groups has now been shown clearly to improve outcome. Beyond that, the remainder of these problems are somewhat unresolved and several reasonable options often exist and are likely to remain so for some time to come.     

Gastrointestinal disease

Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.