case presentations complications intra vaginal mesh...

Case presentations: Complications of Trans vaginal mesh procedures

02 August 2016

Urogynaecology Unit

Tygerberg Hospital

University of Stellenbosch

South Africa

Dr JA van Rensburg

Disclosure

I have the following relationships that could provide the perception of a conflict of interest:

• Research grants:

– Self proposed single incision sling research (Neo medical)

• Sponsorship accommodation FIGO 2015 (Earth Medical)

• Sponsorship registration IUGA 2016 (Boston Scientific)

Introduction

• Case presentations directed to specific

complications from synthetic mesh

• Context of the current algorithm

1. POP: Intra vaginal mesh erosion after SCP

2. SUI: BOO after MUS

3. POP: Pain after anterior compartment single

incision trans vaginal mesh procedure

(4. SUI: Intra urethral mesh erosion after MUS

If adequate time!)

Case 1: Mesh extrusion after open SCP and Halban procedure

• Referred Nov 2014: 66y P3 with vaginal

mesh erosion after open SCP and a

Halban in 2011.

Rx Clavulinic acid and Amoxycillin with

local estrogen vaginal cream

• Main Complaint of vaginal discharge and

pain with a problem of dyspareunia 3/12

Mesh extrusion after open SCP and Halban procedure

Past Surgery included

- Heamorhoidectomy 1992,

- Artificial anal sphincter 1999 and re-do 2003

with loop colostomy for 3/12.

- Total Prolift trans vaginal mesh 2008

with subsequent removal after erosion + infection

- August 2011: ASC with Halban after recurrent

POP + confirmed enterocoel U/S

(Stage: anterior II, middle I, posterior 2-3 by POP-Q)

Case 1:Mesh extrusion after open SCP and Halban procedure

• Intra operative findings 2011

- Deep POD with minimal adhesions

• Procedure:

- Lightweight Polypropylene mesh

- Attach mesh with (00) polypropylene

sutures to anterior and posterior vaginal wall

- Attach mesh to promontorium (0) Polyester

Case 1: Mesh extrusion after open SCP and Halban procedure

• Examination:

- Mesh extrusion 1-2 cm posterior

vaginal wall

- Vault painful on bimanual examination

• Assessment:

66y P3 with >1cm post vaginal wall mesh extrusion with pain and some infection clinically 3 years after SCP

• Management: Excision of erosion UGA

Video excision erosion after Sacrocolpopexy

Treatment Algorithm

• Mesh extrusion > 1cm

• Pain

• Present > 6/12

Options Yes No Level evidence

2. CASE: BOO after MUS

• 45Y P2 referred with OAB in June 2015

not responding to anticholinergic Rx

• Main Complaint progressively worsening

of frequent voiding and nocturia with

some voiding difficulty not being able to

empty the bladder completely after

previous retro pubic sling.

2. CASE: BOO after MUS

Background:

• Mid urethral retro pubic TVT sling 2002

age 32y

• Voiding difficulty with retention: 3/12 CISC

• Developed progressively worsening Sx of

OAB

• Had cystoscopy x 2 with urethra dilatation

2. CASE: BOO after MUS

• Specifically frequency 8x /day and x3 nocturia

and voiding difficulty with incomplete emptying, but no recurrent UTI history

• Clinical examination:

- Stage 1 cystocoele

- Minimal urethral descent

- No pain on palpation

- No erosion or vaginal discharge

2. CASE: BOO after MUS

• Voiding gram:

- Maximum flow speed 14ml/second

- Maximum Bladder Capacity 210ml

- Residual volume 80ml

• Trans Perineal Ultrasound:

- Sling more distally 2.5cm from ext. Meatus

and 2.5mm from urethral lumen

- Minimal descent of Bladder neck

2. CASE: BOO after MUS

• Assessment:

45y P2 with progressively worsening of OAB symptoms regardless conservative Rx and voiding difficulty after retro pubic TVT sling 2002 and obstructive voiding with increased residual volumes and decreased maximum bladder capacity confirmed with a voiding gram

• Management plan: Surgical incision of MUS

Video excision suburethral sling

Postoperatively 6/52

• 6/52 f/up: Patient very satisfied.

- Voiding gram: Flow rate 25sec/min,

Residual 8ml

- Still some frequency, but declined

anticholinergic Rx.

• Any different management options when algorithm is used?

Algorithm

Options Yes No Level evidence

3rd Case presentation

POP: Pain after anterior compartment

single incision Trans Vaginal Mesh procedure

Case 3: POP: Pain after anterior compartment TVM procedure

• 46y P2 known IDDM referred MUI and POP 2011

• SUI > UUI, Bladder sensation intact

• Incomplete voiding, No recurrent UTI

• POP bothersome bulge, POP palpable

• PISQ 12 – usually dyspareunia

• POH: x1 NVD, x1 Forceps assisted delivery

• Known IDDM since age 10y, HT, Hyper cholesterolaemia, Asthma, Depression

• PSH: Vaginal Hysterectomy, anterior repair

Case3: POP: Pain after anterior compartment TVM procedure

• Normal BMI

• No SUI demonstrated

• Stage 3 anterior (Aa= -1cm; Ba= +1-2cm

1 middle (C= -6cm, TvL=10cm)

2 posterior (Ap = -1cm; Bp= -1cm)

• UDS: minimal residual with Max bladder capacity normal at 486ml, flow of 20ml/sec and max Pdet 47cm H2O.

• No SUI with or without reduction at Max Bl. Cap.

Case 3. POP: Pain after anterior compartment TVM procedure

• Assessment: 46y P3 Bothersome anterior and posterior compartment POP with history of MUI and previous Vaginal hysterectomy and anterior repair

• 1. Anterior Elevate inserted

according to standard procedure

2. Posterior repair

Case3: POP: Pain after anterior compartment TVM procedure

• Post operative 6/52 :

- Satisfied and no history of pain

- O/E well supported anterior compartment

- Tender pelvic floor, pain

over the left posterior arm.

• Post operative 3/12:

- Bothersome SUI, deep dyspareunia, hot flushes

- Tender over mesh to the left side posterior

• Rx: Physiotherapy, HRT, NSAIDS

Case3: POP: Pain after anterior compartment TVM procedure

6/12: Ongoing dyspareunia ? History

Left Pudendal neuralgia

Booked PNB with steroid Left

9/12: Nerve block helped but still dyspareunia.

Scheduled repeat PNB, complication of

weakness L. Leg resolved spontaneous. Consult

neurology Diabetic neuropathy.

1year: Persistent pain. Left posterior arm was

excised with acceptable pain relief after

and requested no further Rx

Pudendal nerve block under Ultrasound guidance

• Reasons to use ultrasound:

- Need for accuracy

- Confirm spread of injection solution

- Risk of nerve injury

- Patient comfort

Anatomy PN Posterior access

Video Pudendal Nerve block

Algorithm

Options Yes No Level evidence

Case 4. Excision intra urethral mesh after TVT

• 52y P3 with main complaint of a struggle with her bladder for the last 4 years and background of TVT 1999.

• MUI with SUI> UUI and frequency and nocturia

• Voiding difficulty with incomplete emptying

• X 4 UTI last year

Case 4. Excision intra urethral mesh after TVT

Previous surgery:

• L4-5 Discectomy

• Vaginal Hysterectomy and anterior repair 1994

• RP-TVT 1999 with bladder injury and intra operative repair

Examination:

• 130kg with no SUI in supine position.

• Stage 2 anterior compartment prolapse.

Case 4. Excision intra urethral mesh after TVT

Management:

• Physiotherapy, Oxybutinin, dietician

• F/Up no response and cystoscopy requested which revealed intra urethral mesh erosion

• Booked for Holmium laser removal with urologist

Video Laser excision suburethral sling

Algorithm

Option Yes No Level evidence

Thank You!

Questions!