LAYING THE FOUNDATION FOR AN EVIDENCE INFORMED ALGORITHM FOR MESH COMPLICATIONS
W. CUNDIFF1, K. VAN RENSBURG 2, D. J. QUINLAN 1, M. SLACK 3;
1Department of Obstetrics and Gynecology, Univ. of British Columbia, Vancouver, Canada, 2Univ. of Stellenbosch, Stellenbosch, South Africa, 3Addenbrooke's Hospital, Univ. of Cambridge, Cambridge, United Kingdom.
Introduction: Complications related to the use of mesh in reconstructive surgery are not rare. Most of the literature focuses on incidence and there is a gap in evidence on management.
Objective: The goal is the creation of an evidence-based algorithm for the management of mesh complications, including defining evidence gaps.
Methods: The investigation began with the formation of a panel of surgeons with expertise in treating mesh complications. We utilized the Delphi Method to define a strategy for managing mesh complications that included diagnostic and therapeutic considerations. The first round provided a list of clinically based postulates grounded on experience and knowledge of the literature. This informed a systematic review that included grading of the quality of evidence and expanded postulates to recommendations. [Canadian Task Force] These recommendations were fitted into a management algorithm that was subsequently subjected to a second round of questions of the expert panel. The final algorithm was based on the consensus of the panel.
Results: Based on differences in morbidity and treatment approaches, complications related to mid-urethral slings(MUS), trans-vaginal prolapse procedures(TVM) and sacral colpopexy(SCP) should be managed differently. For MUS, voiding dysfunction can be managed acutely with release in the first -10 days. Dynamic ultrasound has value for recurrent SUI. Erosions without pain may be managed more conservatively although office trimming rarely works. Sling release or vaginal excision is effective for groin pain. More aggressive excision of mesh provides better outcomes for pain, but at the expense of higher morbidity. Transurethral and endoscopic techniques are recommended initially for erosions involving the lower urinary tract . In complications after TVM, lower urinary tract symptoms should be evaluated with cystoscopy. Diagnostic ultrasound appears to be the best imaging modality for locating mesh, but there is no compelling evidence to support an intraoperative role for ultrasound. The ongoing risk of erosion highlights the need for management options that balance efficacy with morbidity. Office management is ineffective for erosions. Partial excision has potentially less complications with similar outcomes to full extirpation. Recurrent POP is more common after extirpation, and a concurrent native tissue repair without additional mesh is indicated. Contrary to MUS, endoscopic treatment of POP mesh in the urethra and bladder is insufficient, and cystotomy or urethrotomy are more effective. Pain following TVM has several etiologies that warrant different management. Pain always includes Levator Ani hypertonicity, so pelvic floor PT peri-operatively is warranted. Pain, including groin pain, should be treated with division of the vaginal portion of the mesh and complete removal of the vaginal wall portion of the mesh Excision of mesh outside the vaginal wall should be reserved for patients with diagnostic evidence of nerve entrapment or chronic infection. Pudendal neuralgia should be considered in patients with mesh arms that go through the SSL. Sexual dysfunction following trans-vaginal mesh for POP can relate to dyspareunia, hispaerunia, and loss of tissue due to contracture and scarring. Hispaerunia can be treated with trimming of the exposed mesh and epithelial closure. Dyspareunia should be managed with division of the vaginal portion of the mesh and complete removal of the vaginal mesh and pelvic floor PT. Reconstructing the vaginal wall in those with loss of tissue is more effective when all mesh is removed first. Erosion is the most common mesh complication after SCP. Conservative office therapy is not successful. Vaginal partial excision with a partial colpocleisis, has a cure rate of 50% with low morbidity but, should not be repeated. Recurrent mesh erosions are better managed with a complete resection via laparotomy or laparoscopy. Mesh erosion into the bladder, urethra or bowel, are most commonly managed by laparotomy. Cystotomy and urethrotomy, with excision and closure seems to be more effective. Some surgeons may be able to achieve similar results with laparoscopy. For erosion into the colon or rectum, laparotomy and complete excision is indicated and may require a diverting ostomy. Erosion that presents with concurrent pain, especially back pain, should be evaluated with MRI to rule out sacral osteomyelitis. MRI is the preferred imaging modality for osteomyelitis and discitus. Patients who do not respond will require orthopedic debridement.
Conclusions: While the quality of evidence is low, the available evidence provides a framework for planning diagnosis and management of mesh complications after reconstructive pelvic surgery.
References: 1. Canadian Task Force on Health Examination. The periodic health examination. Can Med Assoc J. 1979 Nov 3;121(9):1193-254.