SCOTTSDALE, AZ USA (UroToday.com) - Dr. Brian Flynn moderated a panel of clinicians with expertise in vaginal mesh complications.
Pam Moalli, MD, PhD presented “What is the fate of mesh in vivo- shrinkage: Fact or Fiction?” Dr. Moalli reported their data analyzing various mesh products (Gynemesh™, UltraPro M™, and Restorelle™). They implanted the mesh in rhesus macaque monkeys. They looked at the effect upon the vaginal smooth muscle. The greater porosity and less stiff mesh was shown to have the least negative impact. They performed pathologic evaluation of the potential roll of hot immune response to mesh. Encapsulation and contraction, which are presumed etiologies of postoperative pain, were noted to be higher in mesh that experienced a higher deformation of the mesh pore. The unilateral load placed upon mesh caused significant pore deformation, resulting in a reduction of pore size in the Gynemesh™ and UltraPro M™. Loss of mesh length appears to occur from unstable mesh geometries -- early in the postoperative period and later from wound contraction/scar formation. The loss of porosity was noted to result in more encapsulation, which is thought to result in pain. The authors concluded that lightweight and large-pore mesh with stable core geometry provides the most favorable characteristics.
Dr. Daniel Elliott presented “Treatment of bladder and urethral mesh erosion polypropylene mesh erosions: Remove and reconstruct.” He stressed the importance of detailing the patient’s symptoms and doing a thorough exam, as tenderness specific to the vulva, suprapubic region, or vaginal bands may alter treatment plans. Cystoscopy and a rectal exam are key to identifying any perforated mesh. In regards to posterior compartment mesh complications, he feels local resection is adequate provided there is no evidence of infection, abscess, or fistula. His indications for an open repair for mesh removal are: infection, large mesh burden, and erosion. The presence of stones does not influence his treatment. He favors endoscopic laser resection in patients unable to tolerate complex open surgery secondary to medical comorbidities. Regardless of the treatment undertaken, Dr. Elliott emphasized the importance of a detailed discussion with the patient including, but not limited to: realistic expectations post-operatively, recurrent stress urinary incontinence (he quotes ~ 83%), recurrent pelvic organ prolapse (20-30%), mesh complication recurrence, failure to cure pain, and need further additional interventions (42%). For stress urinary incontinence slings he feels removing a small amount of mesh is usually adequate, but he tries to remove as much pelvic organ prolapse mesh as safely feasible. He feels both transvaginal and abdominal approaches are equally efficacious and the surgical approach should be based upon surgeon preference.
Dr. Brian Flynn presented “Ablate and observe.” The data are limited by case reports and small retrospective studies. He advocated for more aggressive transurethral resection rather than endoscopic laser resection. He warned that many endoscopic and minimally-invasive studies are of short follow up. Recurrence rates for endoscopic management were 20-55%.
Moderated by Brian J. Flynn, MD at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) Winter Meeting - February 24 - 28, 2015 - JW Marriott Camelback Inn Resort & Spa - Scottsdale, AZ USA
Panelists:
What is the fate of mesh in vivo- shrinkage: Fact or Fiction?: Pam Moalli, MD, PhD
Treatment of bladder and urethral mesh erosion: Remove and reconstruct: Daniel S. Elliott, MD
Ablate and observe: Brian J. Flynn, MD
Reported for UroToday by Drew Freilich, MD. Dr. Freilich is a graduate of the University of Massachusetts Medical School and completed his urology residency at New York Medical College/Westchester Medical Center. He is currently a fellow in Female Urology, Neurourology and Reconstructive Urology at Medical University of South Carolina. He has authored more than 40 peer-reviewed articles, monographs, abstracts, and book chapters and abstracts. Dr. Freilich is a member of the American Urological Association and the Society for Urodynamics and Female Urology.