Monday, June 1, 2009

Vaginal Mesh Erosion: Part 2

The most common and proven mesh for vaginal surgery is type I polypropylene. It is inert, soft, and has a wide weave to allow tissue ingrowth and acceptance into body tissues. All others are inferior. Many comprehensive reviews of mesh are available and have been published, including my review article in Urology in 2005. We know that mesh reinforced repairs significantly reduce recurrence rates for bladder lift surgery, but is it safe, should it be used, and what complications can occur and how can they be minimized?

Surgeon experience and patient selection are of paramount importance. A doctor who has done 10 mesh cases a year is likely not going to be as proficient as one who does 100 a year, nor as comfortable taking care of complications when they arise. This is common sense. Is the patient’s health and body appropriate for mesh placement: this answer is often easily answered with good clinical judgment based on a history and physical, but there are issues than can exist that may weigh in on a decision, such as: overall health, diabetes, prior radiation or surgeries, immune disorders, etc.

Nothwithstanding mesh properties than either enable it to be incorporated into tissue or not, surgical technique alone can lead to complications. Bladder injury, bleeding, bowel perforation, wrong suture selection are uncommon but significant surgical issues than occur even in the best of hands. That is just how statistics fall out. 99 consecutive cases may go smoothly, but the 100th will have a complication. That is the nature of surgery and human error. That is the whole reason for informed patient consent. Complications can happen to anybody and they must be addressed promptly. Patients should not be embarrassed to question the doctor or bring to light an issue, and doctors should not think themselves perfect. Honesty is the best policy, and the sooner a complication is realized, the sooner it can be addressed.

The most common place vaginally placed mesh can cause a complication is exposure in the vagina. The incision line may not heal well or promptly and mesh will be seen or felt during sex. It can give the sense of pulling or tightness, or cause infection, discharge, blood, or pain. An exam will readily make the diagnosis. Mesh exposure is not a new phenomenon and it well described. Rated can vary between 6-38%. The amount of mesh placed, how it is placed, the quality of vaginal tissue, type of suture used, dissection technique, patient activity during recovery, infection of the mesh, bleeding are all factors related to mesh exposure. Often, local excision, time and estrogen cream will fix this.

A fistula is a very rare complication of any surgery, including mesh surgery anywhere in the body, and the vagina is no different. It is so rare that it is often not clear if it’s related to the presence of mesh or an undetected injury at the time of surgery.

Pain with sex: Dyspareunia. This can occur with bladder drop and is itself an indication for surgery, but dyspareunia is a well known complication of vaginal surgery even without mesh. Overtightening the vagina will lead to pain with penetration. Pain from mesh can occur if it folds or doesn’t lay flat, is too tight or conforms the wrong way around the vagina. Many studies exist on pain or resolution of pain after vaginal surgery with slings (TVT) or bladder lifts. The overall consensus in the literature is that mesh slings improve sexual function and not worsen it. Restoring vaginal anatomy with or without mesh reduces pain with sex, yet there are studies that show a low but significant number of women who have dyspareunia after mesh repair. Some cases are mixed with other vaginal surgeries and so the true incidence is unknown. A detailed sexual history pre-operatively is important in determining the likelihood of this being a factor.

Mesh materials and patient’s bodies change over time. Most biological meshes do not last and lead to recurrence. Synthetic meshes can shrink over time after being scared in. Menopause, weight gain or loss can affect the quality of mesh repair as well.

The FDA released an alert in October 2008 to physicians and patients about potential mesh complications for transvaginal surgery. Most reconstructive surgeons were well aware of these issues and so this was nothing new necessarily, however it highlights the need for public awareness. Although excellent long term data for TVT exists (10-13 yrs), we have at best 5 year data for mesh and bladder repair. Refinement in technique, surgeon experience, product selection and patient appropriateness are all equal factors in successful management of pelvic organ prolapse.

31 comments:

LG said...

Is there a fix to transvaginal mesh injury???? My mother-in-law has experienced it. We live in Southern Ca and we don't know where to start with the process of repair. Please help!

Matthew E. Karlovsky, M.D. said...

You need to see an expert who can deal with mesh complications. If you are near Laguna Beach, I suggest a consultation with Dr Alinsod

Anonymous said...

I had a uterine prolapse 1 year after cystocele and rectocele repair with prograf mesh. Just had TAHBSO with sacral colpopexy and removal of mesh and a bladder calculus. The 1st surgeon didn't do a cysto during the sling repair and the next surgeon had to do a long procedure to dissect the mesh and stone. The mesh was found tangentially in the bladder. What is the rate of success?

Matthew E. Karlovsky, M.D. said...

If all the mesh was removed then you should be able to recover fully. A follow up exam of the bladder can be done to verify

Anonymous said...

I had TVT op 10 days ago. Thnk it was the Monarc sling. I can feel something sharp at the left side of vagina, and it protrudes after passing urine or a bowel movement, i can feel it with my fingers. is it likely to be a suture or part of the tape?

Matthew E. Karlovsky, M.D. said...

@Anonymous from July 8, 2011:From what you describe, it can certainly be the sling poking through the vaginal skin. You'll need to see a urologist or urogynecologist for an exam to confirm and possibly remove the extruding portion.

Becky said...

I need a Doctor.. At 50 years old I had the vaginal mesh surgery april 2011, my first surgery was Aug 2010 at that time I understood I needed a hysterectomy in order to fix my prolasped bladder correctly so I went in for surgery to have both procedures done at the same time after waking up with a laserated colon a colonrectal surgeon was brought in to repair the colon laseration they did perform a complete hysterectomy at that time.the vaginal mesh surgery could not be performed,long story but few days after being home was diagnosed with fistgia and C-Diff and in the hospital twice there after was put on vancomyician until march 2011 in april 2011 I went in for the mesh surgery soon after was diagnosed with a DVT in my leg had really bad pain in leg was on blood thinner for around 6 months my rightleg continues to be very painful daily in the lower back above the back of knee and right where the leg meets my butt I feel the pain in the left leg but not as bad as the right pain in upper middle back? I have had two altrasounds they say no blood clot? Bloating and pain above my belly button is unbearable just my clothes touching is painful in the last three months twice I have had bleeding and pain when urinating for several days at a time call the Doc and perscribed antibotics by phone.I have my prolaspe bladder back again and I don't trust my surgeon I'm so scared I know I'm not right.. I just want to find a new Doctor I can trust! I want my life back!

Matthew E. Karlovsky, M.D. said...

Your experiences and complications are terrible. Unfortunately, if you feel that the prolapse has recurred you need a thorough exam by an expert in prolapse. It is possible that a differnet part of the vagina is prolapsing not related to the mesh.

Anonymous said...

I had the bladder sling surgery in 2002. Last year my gynecologist saw the mesh eroding through my vaginal wall. Is there a specialist in the Atlanta area that can help? Is it a serious surgery to remove the mesh or is it even possible? I have pain off and on, so I would like to get this taken care of as soon as possible. Please help!

Matthew E. Karlovsky, M.D. said...

@LG: In southern Cal, there are urologists (David Ginsberg) or urogynecologists (Red Alinsod) who are trained to place (and removed) mesh. Start there

Anonymous said...

I am in Kansas. I had a TVT in July of "11" . I now have the mesh coming through my vagina. I seen the dr. that did my surgeries. The second surgery was because it was to tight and I could not void at all. I asked for him to explain the surgery to me and the answer I got was " well its not rocket science". He also said he had never done a repair surgery. I am in search of answers and a new Dr. Can you help me please?

Matthew E. Karlovsky, M.D. said...

@Kansas: You need to find a urologist or urogynecologist in your city to get another opinion. You need to determine if the bladder is emptying well, and if the sling is healed and not extruding into the vagina or the bladder

britishgurl30 said...

I had a mesh sling put in for my urethra 6 weeks ago. I went to the dr. for my follow up and he said that some of the mesh was protruding through my incision. He trimmed it and put me on some estrogen cream and told me to come back in two weeks. Is this how it's normally handled? Will this work? What happens in 2 weeks when I go back if there is more mesh??

Matthew E. Karlovsky, M.D. said...

@ britishgurl30:

What you ha sounds like the appropriate course of action. Be mindful of whether the sling is working or not, and exposure of mesh in the future.

Anonymous said...

I had a complete historectomy and bladder lift March 2009. I have had many medical problems since having these surgeries. In may of 2009, I began having respitory problems, Ifound it difficult to urinate and make bowel movements. I was in and out of the hospital the whole month of may that year with breathihng problems, bowels not moving, and having difficulty in urinating. The doctors had diagnosed me with copd, but my lung exrays did not show those symptoms, so they decided that I was having anexiety attacks, and the other problems never got diagnosed even though I reminded the hospital and doctors that I had just had the two surgeries two months before I started having these symptoms. It has been three years since these surgeries and I still have problems with incontinence worse than before surgery. At times I feel a tighteness in my lower abdomen, I have a lot of back pain, thigh and knee pain and a lot of bloating and swelling going on. I am now going to a gynecologist to have all these problems checked out because I have lived with these problems for more than three years.

Matthew E. Karlovsky, M.D. said...

@Anon April 13, 2012-

There are many types of meshes, mesh kits and ways to do the surgery. these need to be hashed out. the first way to discover what was done is to get the operative report, then a thorough pelvic exam and work up looking for areas where the pain occurs must be determined, and potentially a repeat surgery to release mesh areas will meed to be performed. It would better to see a gynecologist or urologist who has done many mesh surgeries and feels comfortable taking care of potential complications. Ask these important questions when you visit

Anonymous said...

Dr. Karlovsky,
I recently had the sling operation. I am 4 weeks post my surgery date. I have this horrible pain that radiates under my buttocks and it almost feels like something is pulling, possibly to tight. I don't have any issues voiding, no bleeding or discharge. I seen my doctor the other day and he said I was still swollen and couldn't tell what was going on and wants me to come back in 3 weeks. I felt like he was just putting things off. I did express to him this is causing me pain. I just want to know what is going on with my body. It's wierd though because when I get up in the morning I don't usually feel it but after sitting down all day at work is when I get this feeling.

Anonymous said...

I had the sling surgery 4 weeks ago. They sent me home without being able to void on my own. I ended up in the ER that evening in excruiting pain because I could not void. I came home with a catheter for two days. Then I got a bladder infection. Then I got what my doctor said was Sciatica pain but I believe something is not right with my sling. I have pain on my right side. I can feel something on the right side. It is painful like something is stitched wrong a pulling type pain. I feel it more when I sit for a period of time and then get up. I don't always feel it when I get up in the morning. My doctor examined me but said he couldn't tell what was going on because I was still swollen and for me to come back in 3 weeks. Knowing that I am in pain he really wants to wait 3 weeks to check me out again. I just need answers. I am a very active person and did this surgery so I wouldn't have issues when I run. Now I am afraid that having this surgery will prevent me from running again. If the sling has to come out would I be able to have another put in and do I really want to have the same doctor do it?

Cathy said...

Can you please tell me if a sling has to be taken out if not put in correctly is it possible for another sling to be put back in?

CJ said...

Hello Dr...
I have been diagnosed with mod/severe SI and am considering the Gynecare TVT to alleviate the issue. In my research to decide if this is what I want/need to help with this embarrasing problem I saw that the chance of complication is lessened if the incision is made through the abdomen vs. vaginally. Have you read/heard of this before? If this statistic is valid, and there is a significant decrease in potential complications, should I insist the surgeon take that "route" or if his/her surgical experience has always been vaginally, should I not "throw a wrench" in their routine and trust in their expereince.
I also have concern, which I havent found much concrete claims/reports on is if the placement of the mesh, even without complications, if there are any effects, either increased or decreased to sensitivity/sensation during intercourse.

Thank-you for your time in answering my questions! :)

~CJ (Spokane, WA)

Matthew E. Karlovsky, M.D. said...

I believe you are getting multiple types of mesh surgereis confused. All slings are done vaginally- TVT or other brands- that is the way they are done. Abdominal route for mesh surgery is for vaginal suspension whiich is a prolapse surgery, not an incontinence surgery which is what you are considering. The TVT and mesh slings like it are best done by those who have done MANY. They are the standard of care and are highly successful

Matthew E. Karlovsky, M.D. said...

@ Anon June 14: Depending on the type of sling procedure- the pain can radiate down the innr thighs or around the buttock. It is usually self limited

Matthew E. Karlovsky, M.D. said...

@ Anon June 14: You may need bladder retraining after your sling. Occasionally self cathterization is needed, but leaving the catheter in a few days for the bladder to recover from the retention is appropriate.

Matthew E. Karlovsky, M.D. said...

@ Cathy on June 14: Once a sling is in it does not need to be removed. It is permanent. Forever. therefore it needs to be placed by a skilled surgeon. If there is sling failure or pain, it can be cut and some of it can be removed. the enitre amount of mesh cannot be removed, usually only the problematic area under and around the urethra. Otherwise the rest is scar. A repeat sling can be done after one is removed.

Anonymous said...

I live in IL and had a bladder sling, with mesh, procedure in 2006. For the first 2 or 3 years, I had no significant pain; since then I've had UTIs, severe pain with intercourse, problems holding my urine until I find a bathroom, abdominal pain and soreness. I've had 2 opinions; one urogynacologist suggested surgery to remove/repair the protruding mesh. The other suggested vaginal cream and Visacare for 2 months, and then be checked again. Any suggestions?

Matthew E. Karlovsky, M.D. said...

To the Illinois woman: be sure to have a cystscopy and urodynamics prior to any sling removal, but I would favor the former opinion.

Anonymous said...

I had sling surgery with mesh sling in 2010.it has worked great for stress incontinence. Just recently I have some of the mesh poke through my vaginal wall. I went to my doctor to confirm. The Dr said I need to repair by trimming exposed mesh and use estrogen cream. It can be done in office with pain meds, or in the OR.
Does anyone know a good mesh repair surgeon in the Dallas Fort Worth area

Matthew E. Karlovsky, M.D. said...

@ Anon in Dallas: don't know of any one but any fellowship trained uorlogist or urogynecologist would be adequate

Anonymous said...

My mom had tvt placed in August 2012, from the moment she woke up she could feel a pull and pain in her right groin area. One week she went to doctor he said oh you are really bruised you have a hematoma. Week two still called it a hematoma. September 20 took to ER thought maybe her hematoma was infected tests came back ok. September 27 her 6 week follow up he mows calls it a swollen lymph node! Took her to my obgyn she doesn't place them or remove the tvt. Found a urogynocologist that got her in for emergency surgery under anesthesia at almost 8 weeks because original doctor only wanted her to use estrace, yet my mom was now using a walker. She had been doing Zumba 3x a week and running on treadmills and now can't walk. The urogynocologist was able to remove the whole length of the tape but there is an upper right portion he just couldn't get out. Is this just stuck there forever? Or would another surgery needed? At one month post op from removal she is walking much better but still gets discomfort when sitting to long and will still get pains in groin at times. Will these eventually continue to get better and decrease over time?

Kc said...

My mom had tvt placed in August 2012, from the moment she woke up she could feel a pull and pain in her right groin area. One week she went to doctor he said oh you are really bruised you have a hematoma. Week two still called it a hematoma. September 20 took to ER thought maybe her hematoma was infected tests came back ok. September 27 her 6 week follow up he mows calls it a swollen lymph node! Took her to my obgyn she doesn't place them or remove the tvt. Found a urogynocologist that got her in for emergency surgery under anesthesia at almost 8 weeks because original doctor only wanted her to use estrace, yet my mom was now using a walker. She had been doing Zumba 3x a week and running on treadmills and now can't walk. The urogynocologist was able to remove the whole length of the tape but there is an upper right portion he just couldn't get out. Is this just stuck there forever? Or would another surgery needed? At one month post op from removal she is walking much better but still gets discomfort when sitting to long and will still get pains in groin at times. Will these eventually continue to get better and decrease over time?

Matthew E. Karlovsky, M.D. said...

@KC: Give it time. the remnant mesh is not a factor. let her recover.