Treatment of Mesh Complications after Prolapse and Incontinence Surgery (What we do)

So, you had surgery to treat pelvic organ prolapse (POP) or stress urinary incontinence (SUI), and now you're worse off than before the surgery.

What went wrong and what can be done to make me better?

Before I can answer either question, I need to understand what your symptoms are now and what they were before the surgery.

How do you do that?

It depends on the particulars of your symptoms, but as a general rule, you'll need to complete a questionnaire, we'll discuss your medical history and then I will examine you.

Been there; done that. What is different about what you do?

I focus on exactly what is bothering you, try to find the cause and develop a treatment plan based on a clear understanding of what is causing the symptoms.

Isn't that what all doctors do?

Not necessarily, some doctors will treat you according to an algorithm, trying this or that treatment and only do a thorough evaluation if the symptoms persist. But let me tell you what I do next.

First, I take a detailed history about the specifics of your symptoms and I examine you. Symptoms generally fall into one or more of the following categories:

  1. inability to urinate (urinary retention) or difficulty urinating
  2. urinating too often and having to rush to the bathroom (overactive bladder or OAB)
  3. urinary incontinence
  4. pain (including pain during sex)
  5. vaginal discharge or bleeding
  6. prolapse

What next?

Of course, that depends on your symptoms and the findings on physical examination. Some patients have only one of these symptoms; others have all of them! Let's take them one at a time.

  1. Difficulty urinating has 3 possible causes:
    • a blockage from the surgery
    • a weakened bladder and pain
    • or anxiety from the surgery itself

    The only treatment for a blockage is surgery, but the success rate is very high. Pain and anxiety from the surgery is usually self limited, but sometimes evolves into a bad habit that is treated with a variety of non-surgical methods. A weakened bladder is the most difficult to treat and may require the use of a catheter to give the bladder time to recover.

  2. Overactive bladder is often temporary and can be treated with a variety of non-surgical methods, but sometimes it is cause by a blockage from the surgery and another operation may be necessary to correct it.
  3. Urinary incontinence has 4 possible causes:
    • a weakened sphincter (sphincteric incontinence or SUI),
    • an overactive bladder,
    • a fistula - a connection between the bladder and vagina which is complication from the surgery
    • overflow incontinence which means that you are not able to empty your bladder and the urine simply overflows and leaks out.
    A weakened sphincter can be treated with both non-surgical and surgical methods and the results are usually highly successful. Overactive bladder is more difficult to treat unless it is due to a blockage - surgery for that is usually successful. The only treatment for a fistula is surgery, but in the hands of an expert surgeon, the success rate is very high. It is essential, though, that the mesh is removed from the fistula at the time of surgery.
  4. Pain is normal after surgery, but it should subside spontaneously as you heal. If the pain persists for more than a month, it should be checked out.

    How do you check out pain?

    The first thing I do is take a history detailing the location and characteristics of the pain. Next is a physical examination to determine whether there are any obvious causes such as erosion of the mesh into the vagina or signs of infection or irritation.

    What next?

    If there are no obvious causes of pain, it is advisable to wait 2 - 3 months because in most instances the pain will go away on its own. Of course during that time, you will be treated with appropriate pain medications or possibly physical therapy, application of heat or cold, etc, If the pain persists, though, a thorough search for the cause will be instituted. In addition to a careful physical examination, cystoscopy is usually necessary and perhaps a an ultrasound, CAT scan or MRI of the abdomen and pelvis.

    If there is an obvious cause of the pain, such a mesh erosion or a stone.

  5. Vaginal discharge or bleeding is also normal for days or weeks after surgery, maybe as long as a month or so. But if it persists beyond that time, it should be checked out. And, of course, any new vaginal discharge or bleeding that occurs once you have recovered from surgery needs to be checked out as well.

    6. How do you check that out?

  6. Prolapse can occur after mesh surgery for two reasons. Firstly, the operation itself may just have failed because the sutures or mesh simply gave way and pulled out of your tissue. Secondly, sometimes only one part of the vaginal wall is repaired by the surgery and the part that was not repaired is subject to more stress, so it weakens and protrudes into the vaginal causing prolapse of a new part. For example, your doctor may have only repaired a dropped bladder (because that is all that was wrong), but after the surgery, your rectum began to bulge out because it became the weakest part once the bladder was fixed.

It is the standard of care and is used in retropubic slings (ie TVT, SPARC), TOT slings and the newer single incision Mini-slings. In prolapse it has been used for many years for the abdominal approach to vaginal vault suspension and is considered standard of care for this procedure (ie abdominal sacralcolpopexy). More recently, it has been used vaginally in Mesh Kits to treat prolapse such as cystocele and rectoceles and when performed by properly trained and experienced surgeons, studies have shown good results with low rates of complications. Mesh is used secondary to the fact that it has been shown in many studies to have higher cure rates versus traditional repairs using the patient's own native tissue. This stems from work that the general surgeons did many years ago showing that hernia repairs with mesh had a much higher cure rate versus using the patient's own weakened tissue.

Mesh technology has improved over the years, as well as techniques of mesh placement vaginally to help minimize risks, unfortunately mesh complications still occur and therefore must be recognized and managed properly. Unfortunately, many patients suffer needlessly secondary to the fact that they are told that nothing can be done and this is far from the truth. While it is true that complications from any pelvic floor surgery are complex (whether mesh has been used or not), true experts in pelvic surgery should be able to handle and treat those complications.or send the patient to someone who does have that expertise.

Types of Mesh Complications Encountered

Type of Mesh and Mesh Technology

Over the years mesh technology has improved and complications have actually been reduced because of this. However, at the same time, because of the increased cure rates associated with mesh graft placement at the time of incontinence and prolapse surgery, more surgeons are placing mesh and therefore more patients have mesh than ever before which will unfortunately will have a baseline risk of complications. An important note though is one has to remember that with ANY prolapse or incontinence surgery, even 'traditional' surgery without mesh, complications do occur including pain, failure or recurrence. The complications associated with mesh may be unique, however in many cases are minor compared to some complications associated with procedures that don't use mesh.

All Meshes are NOT created equal

Studies have shown that a Type I mesh is the best tolerated mesh with the fewest complications seen in prolapse and incontinence surgery. Infection and/or rejection of this type of mesh is very, very rare. These type of meshes are monofilament (ie each strand of the mesh is a single strand and not braided) and macroporous (ie all openings are >75 microns) to allow bacteria fighting cells to gain access into the mesh. They have also recently become lighter, softer and less dense which has reduced complications even further. Drs. Miklos and Moore recently published the largest series in the world with the use of a Type I mesh for Laparoscopic Sacralcolpopexies for vaginal vault prolapse. Overall complication rate was <1% with mesh extrusions <2%. Over the past 3 yrs, Dr. Moore has been leading studies using an even lighter and softer mesh for vaginal mesh placement (Intepro Lite) and has seen complications such as mesh extrusion decrease by 50%. This mesh is 50% lighter, softer and less dense than the previous mesh they were using. This is the future trend in mesh technology, lighter, softer mesh that still has the strength to hold things in place. Older meshes that were NOT type 1 meshes, such as the Obtape sling for SUI, IVS tape for prolapse and grafts such as Gore-tex have been shown to have high rates of infection, abscess, rejection, erosion/extrusion and many of these materials have been taken off the market because of this.

COMPLICATIONS ENCOUNTERED

Although the TVT sling is considered the standard of care in sling surgery today, complications can still occur. It is very important to note that it typically is NOT the mesh itself or the procedure that is the cause of the complication, it is how the mesh is placed or how the body heals around the mesh that is the underlying cause. For example, if a patient is a smoker, her tissue is not as well vascularized as a non-smoker and therefore she is at higher risk of the incision not healing well and then a mesh extrusion occurs. This is NOT the mesh's fault and this patient is a high risk of complications with ANY surgery, whether mesh was used or not. Studies have actually shown that the TVT sling has HIGHER cure rates than traditional surgery for incontinence (ie the Burch or MMK) with LOWER complication rates. TVT sling (Gynecare, Johnson and Johnson) was the first sling of this type on the market and now many other companies have similar products such as the SPARC procedure (American Medical Systems) and others by Bard Urology, Boston Scientific, etc. All of these slings are essentially the same as the TVT as they use needles passed through the abdominal wall and an incision under the urethra to place the mesh tape sling.

Below are examples of TVT-type Slings