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Objective: To provide an update on the literature regarding the management of complications secondary to synthetic mesh placed to treat stress urinary incontinence (SUI)., Methods: We performed a systematic review of the literature using a multi-database structured search within OVID, the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE) and Cochrane library databases; using the keywords: urology, incontinence, mesh and surgery., Results: Several million synthetic polypropylene meshes have been inserted into women worldwide to manage SUI. Unfortunately, a significant number of women have now reported life-changing complications. We found a paucity of studies, heterogeneity of cohorts, poor long-term follow-up, and lack of evidence on the effective management of mesh-related complications., Conclusions: The contemporary evidence is low-level and often contradictory, which prevents robust recommendations regarding treatment. A prospective registry will be required to generate meaningful outcome data and help in the complex management of patients who have mesh-related complications., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Purpose of Review: To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery., Recent Findings: Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

Introduction: The aim of this study was to compare the clinical outcomes of non-absorbable and partially-absorbable mesh intervention in pelvic organ prolapse., Methods: This was a retrospective cohort study of patients who underwent transvaginal mesh operation for anterior and apical vaginal prolapse at a single tertiary center from January 2007 to December 2013., Results: The group treated with partially-absorbable mesh showed better objective surgical outcomes than those treated with non-absorbable mesh in 1- and 2-year follow-ups. Recurrence rate was higher in the group with partially-absorbable mesh than in the non-absorbable mesh group, without any statistically significant difference. Mesh exposure were similar in both groups. Vaginal erosion, dyspareunia and de novo stress urinary incontinence were more common in the non-absorbable group without statistical significance. Buttock pain was more common but not significant in the partially-absorbable group. There were no significant differences in quality-of-life scores after mesh operation between both groups., Conclusion: Patients treated with partially-absorbable mesh showed better objective surgical outcomes with similar postoperative complications than those treated with non-absorbable mesh., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Sacrocolpopexy is one of the most effective surgeries to correct pelvic organ prolapse. Previous studies have described complications, such as mesh erosion and dyspareunia. However, there are few studies on the development of pelvic pain in the absence of mesh erosion in patients who have undergone sacrocolpopexy., Case Reports: We describe 3 patients who presented with apical vaginal pain in the absence of mesh erosion remote from sacrocolpopexy. All patients were refractory to conservative therapies and underwent abdominal excision of mesh with improvement of symptoms postoperatively., Conclusions: The development of de novo pain in the absence of mesh erosion after sacrocolpopexy is an uncommon event but in our cases required complete excision for relief of symptoms. Further research will be needed to understand if surgical technique or materials may be related to the development of symptoms.

Background: Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy., Objective: This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts., Design: This was a retrospective review., Settings: The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy)., Patients: All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999-2013) at these centers were included in the study., Main Outcome Measures: The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity., Results: A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients., Limitations: This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions., Conclusions: Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.

Objectives: To evaluate the technical and patient characteristics associated with the development of mesh perforation and exposure in patients after midurethral sling surgeries., Methods: After a retrospective review of referred patients, the risk of mesh perforation of the urinary tract over exposure in the vagina was analyzed with multivariate logistic regression, adjusting for the possible predictors of age, body mass index, smoking status at the time of mesh placement, presence of diabetes, type of sling placed, type of surgeon and trocar injury at the time of mesh placement., Results: A total of 77 women were identified, 27 with mesh perforation and 50 with mesh exposure. The patients' average body mass index was 29.2, and 13% were diabetic. Nine (33%) patients in the perforation group and two (4%) patients in the exposure group had evidence of trocar injury to the bladder or urethra at the time of mesh placement (P < 0.001). After multivariate logistic regression analysis, trocar injury (odds ratio 25.90, 95% confidence interval 2.84-236.58, P = 0.004) and diabetes (odds ratio 9.90, 95% confidence interval 1.1.25-78.64, P = 0.03) were associated with an increased risk of mesh perforation. Increased body mass index (odds ratio 0.88, 95% confidence interval 0.77-0.99, P = 0.05) was associated with a decreased risk of mesh perforation. Finally, postoperative hematomas and blood transfusions occurred more commonly in the mesh perforation group (15% vs 0%, P = 0.01)., Conclusions: Trocar injury, diabetes and bleeding complications at the time of surgery are associated with higher risk of mesh perforation in patients undergoing midurethral sling placement., (© 2014 The Japanese Urological Association.)

Objectives: In light of vaginal mesh safety concerns, we reviewed our institutional experience with analytic processes and pathologic findings of explanted vaginal mesh to identify problems and opportunities to facilitate improved documentation and research., Methods: We reviewed gross and microscopic pathology reports and archival slides of explanted mesh specimens from January 2010 through February 2012. Specimen requisition clinical history, number of mesh specimens per case, and type of examination (gross or histologic) were abstracted from pathology records using the initial search word "mesh"., Results: One hundred two cases were reviewed. Explanted mesh specimens included tissue in 97%. Forty-eight percent of these cases were submitted for histopathologic evaluation (as opposed to gross examination only). Specimen requisitions listed clinical history as pain (28.4%), vaginal mesh erosion (24.5%), erosion (17.6%), urinary retention (5.9%), and infection (2.9%). When no history was provided (24.5%), the case was more frequently submitted for histologic examination (74% vs 41%, P = 0.05). In all but 2 cases, the mesh material was polypropylene; no requisition mentioned this information. Gross descriptions of mesh varied significantly; in 18% of the cases, mesh was inaccurately described as "metallic". No cases of neoplasm were diagnosed histologically; all tissue diagnoses described benign reactive processes., Conclusions: Our experience suggests that either gross or histopathologic examination is appropriate for mesh explants. Documentation of clinical history, mesh product, and material was frequently incomplete and associated with increased submission of tissue for histologic examination and inaccurate gross impression of material type. We recommend improved documentation to aid pathologic examination and enable future pathophysiologic study of mesh complications.

Background: Over the past several years, the daVinci robot has been used in gynecologic surgery as a new surgical approach. The literature is being slowly populated with pros and cons of this technology., Case: We report a 60-year-old woman with a history of pelvic organ prolapse who had a robotic sacrocolpopexy. She presented with mesh extrusion into her vagina, which was removed by exploratory laparotomy. Two years later, she presented with mesh erosion into her bladder, which was removed., Conclusion: This case report provides an example of significant mesh complication associated with robotic sacrocolpopexy 4 years after surgery and then again 2 years later.

Once thought of as a long-term solution to pelvic organ prolapse, currently synthetic mesh augmentation is regarded as a dark area that is being critically assessed by surgeons, hospitals, industry, and most importantly the Food and Drug Administration. The development of midurethral sling kits has revolutionized the surgical treatment of stress incontinence. These systems, however, were not rigorously tested but instead marketed after being cleared by the Food and Drug Administration through a simple regulatory process using a previously approved predescent material. This article reviews the management of mesh complications of synthetic slings and mesh used to augment prolapse repair., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: despite claims of equivalence to the tension-free vaginal tape, a variety of suburethral slings have been introduced, with various modifications. Complications in certain synthetic slings and meshes have led to a recent FDA public health notification., Methods: we report the case histories and management of five women with complications following implant of an InFast sling., Results: four of the five patients presented with symptom of chronic vaginal discharge, one presenting with irritative voiding symptoms and bladder pain. Resolution of presenting symptoms requires total removal of this silicone-coated polyester mesh, which often requires a combined vaginal-abdominal approach., Conclusions: the silicone-coated mesh of the AMS InFAST sling, can become a focus for chronic infection forming a sinus tract into the vagina or other viscus, causing symptoms years after its placement.

Understanding the occurrence and management of mesh kit complications has become increasingly important. A 54-year-old woman presented to our tertiary care center with complaints of constant perineal pain, and copious, foul-smelling vaginal discharge after anterior and posterior placement of a synthetic mesh and mid-urethral sling 3 months earlier. She was found to have two vaginocutaneous sinus tracts (to the left ischiorectal fossa and to the left labia majora), as well as bilateral abscess cavities within the ischiorectal fossae. The posterior mesh was completely excised, the tracts were opened, and the wound was packed and allowed to heal by secondary intention.

Sparse information is available regarding erosion following biomesh implantation. We report two cases of erosion following anterior vaginal wall repair. In both cases, the operation was performed as a standard cystocele repair where the collagen Pelvicol mesh was anchored to the pubocervical fascia. Both patients had signs of erosion shortly after the operation, and both had the mesh removed. In one patient, the vaginal epithelium healed spontaneously, whereas the other patient had a delayed healing process. The graft was rejected due to intolerance to the biomesh or an infection. Our study shows that an erosion following implantation of a biomesh may be complicated.

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30-83 years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1 months (range 7.5-59.9) in the Gynemesh group and 7.1 months (range 1-21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70 years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3-9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1-0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70 years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.

Introduction: There are few published reports on the incidence and management of urethral and vaginal erosions following the use of polypropylene synthetic slings. Moreover, there is very little Australasian data on their use for management of female urinary incontinence or on their associated complications., Methods: A 1-page survey was mailed to the Australian and New Zealand members of the Urological Society of Australasia (N=326). The survey included questions on the use of polypropylene synthetic sling and the incidence and management of post-operative vaginal and urethral erosions and urinary retention., Results: 198 surveys were returned (response rate: 61%). Polypropylene synthetic sling procedure is practiced by 39% of the respondents with a total of 1459 cases (TVT: 993, SPARC: 466). The incidence of vaginal erosions, urethral erosions and urinary retention was 1.2%, 0.6% and 6.5%, respectively. Thirty five percent of vaginal erosions were asymptomatic and only identified on routine post-operative vaginal examination. One third of urethral erosions presented more than 1 year after surgery and 89% of these were symptomatic. Thirty four percent of patients with urinary retention required surgical intervention to correct the retention., Conclusions: The incidence of urethral and vaginal erosions following polypropylene synthetic sling procedures is lower than that with other synthetic slings. However, a high index of suspicion and long-term follow-up are required to identify and manage these complications of this relatively new procedure.

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.

Background: Abdominal sacral colpopexy with permanent mesh has become the preferred abdominal technique for correcting posthysterectomy vaginal vault prolapse. Although rare, mesh erosion after sacral colpopexy is often challenging to manage. We report on 3 cases of mesh erosion after abdominal sacral colpopexy managed by transvaginal endoscopic removal of the mesh., Cases: The cases involve patients who underwent an abdominal sacral colpopexy and had vaginal mesh erosions within 3 years of their surgeries. Conservative and traditional transvaginal techniques failed, and the patients continued to complain of vaginal discharge. All patients underwent transvaginal endoscopic removal of the mesh and are cured of their chronic discharges., Conclusion: Transvaginal endoscopic removal is an effective, minimally invasive option for removal of eroded mesh after abdominal sacral colpopexy.

We describe the triple operation for prolapse with prosthesis in patients with pelvic organ prolapse using a vesicovaginal mesh for the cystocele, a rectovaginal mesh for the rectocele and a posterior retro-and trans levatory vault suspension sling. Preliminary results in a consecutive series of 92 patients who underwent surgery between June 2001 and December 2002 showed three cases of vaginal erosion in contact with the prosthetic material, and one hematoma of the pararectal fossa with secondary abscess formation requiring ablation of the implant. There was one immediate anatomic failure. Function was good with no reports of dyspareunia or dyschesia.

Objective: The aim of this study was to describe conservative surgical management of polyethylene terephthalate (Mersilene, Ethicon, Inc, Somerville, NJ) mesh suburethral sling erosion as an alternative to sling removal., Study Design: Seven women who had undergone suburethral sling procedures with Mersilene mesh were found to have varying degrees of mesh visible in the vagina at 4 to 12 weeks after the operation. Three women with erosions <5 mm were treated in the office and 4 women who had 6 to 30 mm erosions underwent inpatient surgical revision, which consisted of trimming of mesh when needed, excision of granulation tissue, and re-covering of the erosion in 2 layers., Results: All 7 patients have been followed up for 6 to 37 months. Only 1 woman who underwent inpatient surgical revision had a recurrence (4 mm); this was treated successfully in the office., Conclusion: Vaginal erosions in suburethral sling procedures with Mersilene mesh can be managed initially with our conservative surgical technique.

A new surgical technic is described, for the vaginal posterior hernia (enterocele). The authors used the "Marlex" mesh in 6 patients with success.