Mesh

Controversial and evolving area with high rates of litigation and subsequent government intervention.

Polypropylene mesh has been used for decades in various surgeries.

For many women, the use of mesh in pelvic surgery has been problem-free and led to great improvements in their condition and quality of life.

• However, for some patients, they have had complications which can be catastrophic.

Widespread media attention and patient support groups has intensified the focus on mesh devices.

 

History

• TVT 1995 – success prompted widespread development
• 2001 – pelvic organ prolapse mesh kits approved
• 2008 – first FDA safety warnings for POP mesh
• 2018 – TGA banned all transvaginal mesh for POP, and mini-slings for SUI.

 

Vagina has unique properties which may predispose to complications:

• Significant physiological stretch
• Proximity to hollow viscera – bladder, urethra, rectum
• Abundant microbiome

 

Risks for mesh complications:

• Patient factors
  • Obesity, steroids, healing disorders, radiation, post menopausal atrophy, prior surgeries, diabetes, sexually active, concurrent hysterectomy
• Device factors
  • Transvaginal prolapse mesh ++ – greater area of dissection, larger mesh
  • Multifilaments higher risk
  • Smaller pores higher risk
• Surgeon factors
  • Low volume, inexperience

 

Pelvic prolapse mesh trial 2017 – no difference in patient outcomes for anterior or posterior repair mesh vs native tissue – 12 % of mesh group had mesh complication.

 

Meshes are categorised as type 1 to type 4 based on pore size:

• Type 1 has pores > 75 um – allows tissue, macrophage and blood vessel ingrowth, reducing infection and erosion rate
• Polypropylene is type 1
• Smaller pores may allow bacteria (1 um) but not macrophages and tissue growth

 

Potential issues with mesh:

• Pain – acute and chronic
• Chronic infection
• Mobility concerns
• Vaginal bleeding
• Voiding dysfunction including obstruction or overactivity
• Erosion – vaginal, urinary, rectal
  • Extrusion or erosion rates may be 10 – 15 % after transvaginal prolapse surgery
• Dyspareunia and loss of sexual function
  • Up to 10 % de novo
• Psychological impacts
• Contraction
• ?Systemic and autoimmune impacts

 

If using mesh:

• Thorough consent and patient counselling pre-operatively
• Audit and transparent database to follow outcomes
• Report any adverse events
• Should ideally be high volume centre
• Specialist training
• Track device numbers / records of implantables
• Ensure patients are followed up and concerns acknowledged

 

USANZ position statement:

• Use of monofilament polypropylene mid-urethral slings is a reasonable treatment option
• Robust evidence for MUS from over 2000 publications

 

Managing mesh complications:

• Low threshold for exploring any symptomatology in patients with previous mesh
• MDT approach – urology, gynaecology, physio, psychology, pain specialist, nurse, GP
• High volume specialist centres
• Pelvic pain may have complex aetiology and may not be relieved after mesh removal

 

Vaginal exposure

• Usually transvaginal removal of exposed segment
• Topical oestrogen adjuvant to maximise healing
• Can consider conservative treatment is asymptomatic, no infection and < 10 mm
• Removal
  • Careful counselling – may be impossible to get all
  • Balance between trying to relieve symptoms and causing complications

 

Pain after urethral sling

• Need to take thorough history and localise pain prior to any intervention
• If acute severe pain immediately after placement – should probably remove early before tissue ingrowth
  • Imaging prior to exclude haematoma which can be managed conservatively
  • Point tenderness over sling warrants excision
• Consider other causes – pelvic floor tenderness (physio), dyspareunia from post menopausal atrophy (oestrogen)

 

Groin pain

• Transient groin pain usually settles after a few weeks
• Options include oral analgesia, local injections or steroid injections or nerve blocks
• Recalcitrant pain warrants removal of TOT – usually requires obturator dissection combined with vaginal dissection – difficult

 

Urethral exposure

• Urethral injury during placement mandates abandoning ship
• Minimally invasive urethral removal – cystoscopy and laser, nasal speculum for direct removal
• Urethrolysis with full removal of mesh is more definitive
• If urethra needs to be opened – careful meticulous closure +/- Martius flap

 

Bladder exposure

• Removal of any stone formed on exposed mesh
• Holmium laser excision or “endoscopic scissors”
• Lap port / suprapubic trocar and use lap instrument for tension
• Open excision / partial cystectomy via cystotomy

 

Mesh infection

• Removal of entire mesh should be aimed for – may require abdominal approach in case of sacrocolpopexy
• MRI may be needed for imaging