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Complications Related to the Use of Mesh and Their Repair

Shlomo Raz; Lisa Rogo-Gupta

Questions

1.Which of the following statements is TRUE?

a.Urinary obstruction always presents with elevated postvoid residuals.

b.Mesh exposure is necessary to diagnose a patient with mesh complications.

c.Vaginal estrogen sometimes resolves mesh exposure.

d.If a patient does not have complications 3 months after mesh insertion, no further follow-up is needed.

e.De novo lower urinary tract symptoms are never a sign of mesh complications.

2.Evaluation of a patient with possible mesh complications includes:

a.history and review of medical records.

b.history and physical examination, conversation with the original surgeon.

c.history and physical examination, review of medical records.

d.history and physical examination, diagnostic imaging, review of medical records.

e.physical examination and diagnostic imaging.

3.Which of the following correctly identifies a possible surgical complication?

a.Levator ani pain after mesh placed vaginally for rectocele repair

b.Sacral pain and osteomyelitis after mesh placed vaginally for cystocele repair

c.Rectal penetration after midurethral sling

d.Rectus muscle pain after mesh placed vaginally for rectocele repair

e.All of the above are correct

1.c. Vaginal estrogen sometimes resolves mesh exposure. Answers a, b, and e suggest that complications always present similarly, which is incorrect. Answer d suggests that complications always present within 3 months following insertion, which is also incorrect. Complications may present in a variety of ways, and at any time.

2.d. History and physical examination, diagnostic imaging, review of medical records. History and physical examination are essential components of evaluation. Review of medical records and diagnostic imaging may also be useful in select patients.

3.a. Levator ani pain after mesh placed vaginally for rectocele repair. Levator ani, gluteal pain, and rectal penetration have been described after rectocele repairs performed with mesh augmentation. Sacral pain and osteomyelitis have been described after suspensions of the uterus, cervix, or vagina to the sacrum. Rectus muscle pain is typically described after midurethral sling placement.

4.a. Abdominal radiograph for mesh location. Abdominal radiograph is not commonly utilized for identification of mesh location. Answers b, c, d, and e all describe diagnostic studies that may be useful in select patients.

5.e. All of the above. The term "mesh products" is used to describe a multitude of products. Variation exists in product composition, fixation mechanism, shape, and additional features.

6.e. Routine annual follow-up. Patients with complications should be followed up closely for improvement, and answer e is appropriate for patients without complications.

7.e. a, b, and d. This describes the recommended counseling for patients undergoing mesh placement procedures.

8.d. a and c only. There is a 20% risk of recurrent anterior prolapse after mesh removal.

Chapter review

1.With the use of mesh in the vaginal area, there is a 10% erosion rate and up to a 28% incidence of dyspareunia.

2.Pain complications on occasion cannot be reversed, even with complete removal of the mesh.

3.Mesh exposure and dyspareunia may occur years later as vaginal atrophy occurs with aging.

4.There is a 30% to 50% risk of incontinence following sling excision, and

a 20% incidence of anterior compartment prolapse.