Complications of mesh in gynecologic surgery

1. Complications of Mesh in
Gynecological surgery
(ACOG COMMITTEE OPINION)
Prepared by
Osama Elsayed
Assistant Lecturer of OB & Gyn
Zagazig university

5. In 1996, Boston Scientific’s ProteGen mesh, the first
vaginal mesh for the surgical treatment of SUI was approved by
the FDA, However transvaginal mesh was not approved for use
in the treatment of vaginal prolapse until 2002.
Since then MUS for SUI and abdominal mesh for
prolapse were found to be safe and effective with minimal
complications.
HISTORY OF MESH USE

6. The transvaginal mesh was successful in correcting
prolapse, however unforeseen adverse events such as
mesh exposure and vaginal pain were not insignificant and
frequently difficult to treat.
The use of synthetic mesh in transvaginal prolapse
repairs & incontinence has not been without controversy.
At the heart of the controversy lies the concern that
complications related to mesh use outweighting the
benefits.
HISTORY OF MESH USE

7. According to its nature
1- Synthetic absorbable mesh
• composed of polygalactin or polyglycolic acid.
• undergoes replacement by collagen-rich connective tissue
• poor long-term tensile strength and early recurrence.
2- Synthetic partially absorbable mesh
• collagen-coated polypropylene mesh
• insufficient evidence to support the use of partially absorbable
synthetic mesh.
CLASSIFICATION OF MESH

8. 3- Synthetic non-absorbable
• Provide more consistent and durable tissue strength,
• The most significant limitation is reaction by the host to the
foreign body, infection and mesh contracture or exposure.
• Pore size significantly influences mesh density and flexibility,
infiltration by macrophages and bacteria, and subsequent risk
of infection and mesh exposure.
• non-absorbable mesh was classified by Amid in 1997 and is
based on pore size
CLASSIFICATION OF MESH

9. Type 4Type 3Type 2Type 1
< 1m> 75m< 10 m> 75 mPore size
Submicronic
pores
Macroporous
multifilametous
microporousmacroporous and
monofilametous
Description
TunnelerGORE-TEXProlene
Ethicon,
Example
rigid and
therefore
unsuitable for
use in the
vagina.
similarly to
type 2
-Bacteria
infiltrate so 
infection
-collagen
fibres
macroph not
infiltrate so 
incorporation
infiltration by
fibroblasts, blood
vessels, collagen
fibres macroph
incorporation
 infection
Advantage
Or
Disadvantage
Not used in
vaginal
surgery
preferred
choice for
vaginal surgery
use

10. A – Stress urinary incontinence
 Retropubic mesh tape procedure.
 Transobturator mesh tape procedures.
 Single incision mini-slings.
B – Pelvic organ prolapse
 Anterior colporrhaphy with mesh insertion.
 Posterior colporrhaphy with mesh insertion.
 Abdominal sacrocolpopexy.
USES OF MESH

12. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- Vaginal mesh exposure
4- Bladder & urethral erosion
5- Pain
MIDURETHRAL SLING

13. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- vaginal mesh exposure
4- bladder & urethral erosion
5- pain
MIDURETHRAL SLING

14. • Occur immediately postoperative & up to 6 weeks
• Include : retention, small volume voids and large postvoid
residual volume.
• Due to : periurethral tissue edema, anesthesia / opiate
effect , pain & bladder outlet obstruction
• Management :
- most cases will resolve spontaneously.
- a trial of voiding before discharge will determine if the
patient is at risk of overdistension
1- Short term voiding dysfunction

15. - use intermittent self catheterization till the postvoid
residual volume is < 150 ml for 3 successive voids.
- use of indwelling catheters with voiding trials weekly till
the postvoid residual volume is < 150 ml.
- Sling release is indicated if retention occurs or if the
postvoid volume is > 150 ml for 6 weeks.
1- Short term voiding dysfunction

16. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- Vaginal mesh exposure
4- bladder & urethral erosion
5- pain
MIDURETHRAL SLING

17. • Occurs 3 months postoperative.
• Include :
high pressure voids  uretral reflux  hydroyreter &
hydronephrosis  affection of kidney functions.
• Due to :
Bladder outlet obstruction
• Management :
- evaluate the baseline voiding pattern & urodynamics.
- search for DM or neurologic disorders.
2- long-term voiding dysfunction

18. • Urodyanamics including : uroflowmetry to
assess voiding pattern, postvoid residual volume,
filling cystometry to assess detruser function.
• BOO is diagnosed by low flow rate + high
detruser pressure.
• Treatment : sling release.
2- long-term voiding dysfunction

19. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- Vaginal mesh exposure
4- bladder & urethral erosion
5- pain
MIDURETHRAL SLING

20. • Defined as exposed mesh visible
or palpable through the full-
thickness vaginal wall.
• Incidence : is rare after midurethral
sling, occurring in 1–2 % of
patients.
3- Vaginal mesh exposure

21. • Manifestations:
symptoms may begin within a few weeks to a few
months after the procedure
Pain, bleeding, discharge, dyspareunia & partner
dyspareunia.
 Sling visible or palpable on physical examination.
3- Vaginal mesh exposure

22. • Management :
1- Expectant treatment + local estrogen cream ( if type
1 mesh is used & patient is asymptomatic).
2- Excision of exposed edges & suturing the fresh
edges ( with eversion of the edges & without tension).
3- Full thickness autologous graft . e.g. martius graft.
4- Excision of the mesh.
3- Vaginal mesh exposure

23. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- Vaginal mesh exposure
4- Bladder & urethral erosion
5- Pain
MIDURETHRAL SLING

24. • Manifests by: dysuria,
frequency, bladder stones &
fistula formation.
• Management :
1- Combined cystoscopic &
vaginal excision of the eroding
mesh. Martius or other flap can
be used for additional coverage.
4- Bladder & urethral erosion

25. 2- If urethral erosion ; endoscopic techniques or
open transvaginal excision.
ENT instruments or hysteroscopic scissors through
a cystoscope could be used to avoid urethrotomy.
4- Bladder & urethral erosion

26. 1- Short term voiding dysfunction
2- Long term voiding dysfunction
3- Vaginal mesh exposure
4- Bladder & urethral erosion
5- Pain
MIDURETHRAL SLING

27. • Incidence : very common 20%.
• Manifests by: vaginal pain, chronic pelvic pain &
dyspareunia.
• Management :
1- Determine if the patient had any chronic pain prior to mesh
placement.
2- Full exam to localize anatomy involved in the pain & to
determine if this pain is related to the mesh.
3- Rectal exam should be performed to assess tone and
evaluate for pain or mesh perforation
5- Pain

28. 4- Pelvic floor physical therapy, trigger point local
injection, analgesics up to medications of neuropathic
pain.
5- Botulinum toxin A has been used to improve pain
related to levator spasms.
6- Excision of the mesh ( However, the patient should
be counseled that pain is not releived in about 50 % of
cases).
5- Pain

29. 1- wound complications
2- Vaginal mesh exposure
3- pain
4- perforation of the bladder or rectum
TRANSVAGINAL MESH FOR
PROLAPSE

30. • Defined as exposed mesh visible or
palpable through the full-thickness vaginal
wall.
• Causes : wound separation, infection, or
vaginal atrophy.
• Manifestations:
symptoms may begin within a few hours to
a few months after the procedure according
to the cause.
Pain, bleeding, discharge, dyspareunia &
partner dyspareunia.
 mesh visible or palpable on physical
examination.
Vaginal mesh exposure

31. • Management :
1- Expectant treatment + local estrogen cream ( if type
1 mesh is used & patient is asymptomatic).
2- Excision of exposed edges & suturing the fresh
edges ( with eversion of the edges & without tension).
3- Full thickness autologous graft . e.g. martius graft.
4- Excision of the mesh.
3- Vaginal mesh exposure

32. • Perforation into the bladder is
previously described.
• The mesh perforation into the
rectum is treated by creating
Mucosal flaps around the exposed
mesh. The mesh is then dissected
off of the underlying rectal wall and
excised. The mucosal flaps are
closed with vicryl suture.
Perforation of the bladder or rectum

33. • Include : infection, sinus tract formation, granulation
tissue formation
• Management :
1- Full exam to exclude mesh exposure.
2- Antibiotics.
3- Chemical cautery.
Wound complications

34. 1- Vaginal mesh exposure
2- Sacral osteomylities & discitis
3 – Mesh erosion into viscera
ABDOMINALLY PLACED MESH
FOR SACROCOLPOPEXY

35. • Manifests by: pain, bleeding & partner dyspareunia.
• Management :
1- expectant treatment + local estrogen cream ( if
monofilament mesh is used & patient is asymptomatic).
2- excision of visualized mesh ( if symptomatic , persistent,
or monofilament mesh is used).
3- if the above failed ; excision of the mesh by laparoscopy
or laparotomy.
Vaginal mesh exposure

36. • Manifests by: severe back pain postoperative.
• Caused by : faulty placement of sutures in L5/S1
disc ( it is the most prominent point not the sacral
promontory)
• Investigations: non contrast MRI.
• Management:
1- expectant treatment + antibiotics.
2- if abscess is formed ; surgical drainage + mesh
removal + debridement & reconstruction of sacrum
& lumbar disc.
Sacral osteomylities & discitis

37. • The mesh may erode into bladder , rectum, or
intestine
• Treated by surgical removal of mesh & repair of
eroded organ, resection anastomosis or
colostomy.
Mesh erosion into the viscera

38. Preoperative measures
• Initiation of vaginal estrogen supplementation 4–6
weeks preoperatively to improve perioperative
tissue quality.
• Very careful consideration of risk profiles should be
undertaken in Patients who had pelvic radiotherapy,
those on steroids, immunocompromised, with
chronic diseases or smokers.
How to Minimize the complications

39. Intaoperative measures
• Optimal vaginal wall thickness during dissection is
essential to avoid vaginal wall thinning.
• Hydrodissection is performed prior to incision to
creates a submucosal space.
.
How to Minimize the complications

40. Postoperative measures
• Try to minimize the vaginal wall hematoma &reduces
the risk of postoperatively bleeding by placing a
vaginal pack as hematoma may cause mucosal
separation with mesh exposure as the hematoma
liquefies and drains and it can be removed within 24 h
after surgery
How to Minimize the complications

41. • The mesh may erode into bladder , rectum, or intestine
• Treated by surgical removal of mesh & repair of eroded or
colostomy.
Mesh erosion into the viscera