Hello, everyone, and welcome to the AUG's FPMRS webinar series. I'm Pam Fairchild, and I'm going to be moderating today's webinar. Our webinar today is the Clinical Management of MeSH Complications, which will be presented by Dr. Vincent Lucente. Dr. Lucente is going to do about a 45-minute presentation. We'll leave 15 minutes at the end of the webinar for questions and answers. Please feel free to put your questions and answers, questions in the Q&A box below as we go along. We'll address those at the end. Dr. Lucente is the Medical Director for the Institute of Female Pelvic Medicine and Reconstructive Surgery and FPM Urogynecology Center in Allentown, Pennsylvania. He's also the Chief of Gynecology in the Department of Obstetrics and Gynecology at St. Luke's University Hospital in Bethlehem, Pennsylvania. Most importantly, he's an expert on transnational MeSH placement and complications, and we're really excited to hear him speak today. Before we begin, I'd like to review some housekeeping items. This webinar is going to be recorded and is being live-streamed. Please use the Q&A feature of the Zoom webinar to ask any of the speaker questions. The chat feature should be reserved for technical issues, and our OGS staff is going to be monitoring that. So if you're having issues, please put those in the chat, and we'll address those as they go along. So without further ado, we'll let Dr. Lucente get started. All right. Thanks, Pam, and good evening, everyone. Thanks for taking the time out of your busy schedule to tune in and listen in about things I can share with you about my experience with taking care of patients who had transnational MeSH complications. I often say no one has placed more transnational MeSH than myself, and I very often will make it clear that I think the majority of complications that arise aren't due to the MeSH. No implant gets out of a box and places itself, be it a cardiac valve or a knee replacement, right? So implant-based surgery versus excisional-based surgery, where we're taking out a diseased organ, be it an enlarged ovary or fibroid. Most of the time, most of the surgeons get that mostly right. But my experience of doing MeSH, teaching MeSH, and observing others' videos, unfortunately, there has been suboptimal physician placement of materials, and that could be small pieces of MeSH under the urethra or larger placements for pelvic organ prolapse. And unfortunately, I think most of us know the way this has gone due to the complications, adverse events that arose, that the easier answer to the problem was to simply no longer have it be made available. And I think that was a real setback to our patients because, again, I thought it was one of the best surgeries I had to offer. And I'll continue to sort of make that message known, and anybody who cares to listen, and I would encourage you all to sort of open up a little bit about everything you may have heard or witnessed or somehow entertained as sort of being an anti-transvaginal MeSH person. And if you own more of it, and I would often talk to how I would speak to patients about it, and people like Peter Rosenblatt from Boston would point out, well, Vince, you're basically telling the patients that if anything goes wrong with their transvaginal MeSH surgery, it's your fault, if you will. And I said, well, it kind of is, isn't it? If anybody should really own anything, it should be you, the surgeon. And I think that translates into a lot of confidence to the patients that you are an expert at what you do. And we'll get into, you know, when no one plays a perfect game. So have I had exposure? Sure. And do I own up and own that exposure? Yeah. So if I talk to a patient about exposure, I say there's an area here where I didn't place the MeSH as deeply or as far into the pelvis as I wanted to. It was too superficially placed by yours truly, and now it's exposed, and patients appreciate that a lot. So please try to get out of the blame game of blaming products and procedures and try to own a little bit more of it. And I think that plays well, too, of just owning the complications and being well-prepared. So here's my disclosure slide. I think the most relevant is at the bottom. I do tend to mumble, and I'm not wearing a mask tonight, so that's a little bit better. And I've been known to cuss, but lately I've heard that's a sign of intelligence. So at my cursing rate, I'm probably working on becoming a savant. I didn't want to sort of waste a lot of people's time talking about methods of transvaginal MeSH placement because it really isn't available to us. I mean, obviously, you're allowed within the scope of practice to use something that you would consider a quote-unquote off-label. But the manufacturers have stopped making kits. Have I resorted back to the days of cutting MeSH from hernia pieces and placing them the way I did in 204, 203, and before the commercialization of MeSH kits? Yeah, I would. I haven't. I would reserve that to an inner circle of people. In today's legal environment, I would trust when taking to court if something happened, or I wouldn't be hung up in some town square. So there'd be family and friends and others that I would feel comfortable doing it, but I would do it in a New York heartbeat. Like all complications, the sooner you recognize them, the better off everybody is. You feel better. Patients feel better. So the early recognition and prompt response is always going to play well, and I'll talk a little bit about how do you do that, and mostly it's about listening carefully to the patients. The same thing when they come in with their conditions, right? The closer you listen, the better off you're going to diagnose things. That's the same thing with complications, and recognize that when someone tells you they're having persistent discharge, they are, and if they're having spotting, they are. They usually don't make these things up, and so believe your patient's symptomatology sincerely and holistically, and it behooves you to listen to those symptomatologies carefully and then go upon your mission to diagnose those and find those, and I would say that you'll always feel an exposure usually before you'll see it, especially the smaller ones. So any polypropylene material that makes its way through the vaginal epithelium, you're going to see it. I'm sorry, you're going to feel it much often before you see it, especially small little fibers. And your management, obviously it's going to be a combination of surgical and non-surgical. The non-surgical things we'll go through first, but there are times where I go right to surgery because I know there's no non-surgical technique that will ever address this particular complication, and we'll talk about that in both in terms of exposure and pain, which is going to be the lion's share of the talk. And then finally, just a little medical-legal thoughts and considerations, and nothing earth-shattering, but it's something I think is very important in today's day and age, where we're finding the legal profession, the legal world, shaping the hearts and minds and decision-making of our patients, even more so than I. As a matter of fact, two patients today were kind of dug in on their anti-mish positioning. One was a patient yet to have surgery, and sadly was actually looking to have a copal clysis. She's in her early 70s, and the husband's healthy, and we had a very frank discussion towards the end, and I'm 62, and hopefully in the early 70s, I'm not throwing in a towel with intimacy. And it was just an incident that she wanted a copal clysis, and I've been talking herself into that, and actually heads up some copal clysis support group, but I wasn't quite gathering all of that. But has dug herself into that mesh is not an option, even abdominal replace, and so we spent an inordinate amount of time with that patient, and it was scolded by my nurses, but I got her to believe, at least to open her ideas of mesh, and the second patient was interesting. My patient came to me, and I couldn't do transvasal mesh, and actually sent her to Pat Tulligan, who's nearby, who I think is a master of robotic sickle-copal plexus, and she wound up going there, but yet talking, refusing to have mesh. So it still happens that patients aren't making good choices for them, because they're listening more to the legal airways, and the social media, and chat rooms, and other things, than they are to us as the doctors, and that's a very sad, but true statement. So we'll start off with the elephant in the room, which is vaginal exposure. There's a great article out there, as a matter of fact, here's a shameless plug, I have it sitting right here on the desk in front of me, so this article is a joint position statement on the management of mesh-related complications for the FDR specialists. So this is written by our AUGS people in combination with the IUCAA folks, and it's out in the 2020 February issue, go online and find it, I think it's volume 31, but I can tell you, this is one of the best written, comprehensive articles on this arena that I've ever seen, and I've referred to it a few times before I actually moseyed up to the computer tonight, and I think it's extremely well-written, it's one of the things that AUGS does best, is when they get a group of smart people with experience together to pore over the literature and have a blending of evidence-based literature and roundtable experience and come away with a good reference document, and I'll encourage you all to read that. So again, exposure is the elephant in the room, it's the big one, right, it happens no matter who you are, you need to be able to, you know, try to prevent it, whether it's abdominal mesh, making sure, again, if you can leave a cervix, leave it, but anytime you make an incision, you've opened up the door for possible exposure, and making sure that you don't have, you know, any kind of ischemic necrosis or thinning of the vaginal wall, remember the vagina has four layers, histology, that make up the vaginal wall, there's the mucosa, this lamina propria, submucosa, then there's the muscularis, and there's this little connective tissue capsule, if you will, the serosa, and the mesh belongs behind all of those, right, so the problem with vaginal mesh is putting mesh, you know, that came in transvaginally, rather than dissecting all through all four layers and getting that mesh up where it goes, sort of tag, you're it, when you come abdominally, you're automatically there, mesh was, and this happens too with our slings, you know, these materials are placed submucosally, worst word ever, right, never, ever, ever, ever place a material, a synthetic polypropylene mesh below the epithelium of the vagina, because you're asking for an exposure, these do not belong there, they need to be submuscularis at best, it's going to be based on symptom size and location, remember, you can't make an asymptomatic patient feel better, it's impossible, so even though you see fibers or small, you know, again, it should be fibers, and even, I would say, less, much less than a centimeter, but you see a tiny little area of exposure, and the patient has no symptoms whatsoever, leave that alone, you can, I'm a big fan of transvaginal estrogen, making sure we optimize vaginal health, it's for a whole slew of reasons, but again, it's at least going to help minimize or promote vaginal tissue wellness and health so that you have got, you know, a more maturation index of the vaginal epithelium, and less likely that exposure will get any larger, so if you see her next year and you follow these patients up, that small, tiny, asymptomatic exposure isn't bigger, so that's a very good reason to do it. Despite size, if it breaks the plane, what I mean by that, if this is the plane of the vaginal epithelium, sorry, it's my phone falling, if your exposure breaks that plane, I don't care how small it is, that's never going to heal, no matter how much time or vaginal estrogen you give the person, but if it's below the plane, so now you've got a break in the vagina epithelium, and you look down, you can see mesh below that plane of the vaginal mucosa, those will, if they're small, and estrogen will tend to re-epithelialize over the top and disappear, so again, it's more about that three-dimensional, does it break, or you know, the plane of the vaginal epithelium, three-dimensionally, and if it does, game over, it's not going to re-epithelialize and disappear with time and estrogen, and more so than size, and more important to me than size is that three-dimensional thing, but again, I wouldn't try to, you know, do conservative management, something that's greater than one centimeter, it's kind of a rough cutoff, the article speaks to that as well, and then again, location is going to be important in terms of how you may approach it, things that are very low, easy access, I have, you know, and there's a big anti-office trimming, and I wouldn't do that if it happens to be exam room three that's open, but if you have a procedural room in an office, so the devil's in the details, right, you got the right lighting, the right instrumentation, you have local, you have time, you've actually scheduled it as a office-based procedure, and I think you can mimic, and I can talk about that, I think you can very much replicate what you're doing in the OR, but only in the lower aspect of the gyne, there's no way you're going to do that on the upper, you know, apical area, or in a tough antilateral sulcus, so location is going to come into play. I'm a big, you know, fan of infiltrating and using local, you know, with my surgical placement and dissection, so I'm a big fan of hydro-dissection, helping fluid, help us develop planes, or more often spaces, right, we like to work in pelvic spaces, and which are different than planes, right, planes exist between histologic layers, spaces exist in between organs and sidewalls, and you know that locally, you know the pelvic spaces, but these infiltrations can help us develop those during our dissection, same thing with complication of getting, you know, excising something, if you can get the fluid to do some of the surgical mechanical work of separating the material, the implant from the surrounding tissue, it's going to help you a long way, especially the vasopressin, right, it's hard to see what you're doing if you're in a pool of bleeding and can't really stop it, so I always tell patients, you know, it never meant exposure, I didn't cure, and people say, well, I was told it, you know, it can't be removed, that's not true, I will remove it, it may take me a while, when my daughters were little, they would bring me these tiny little necklaces with a huge, the biggest knot in this necklace you've ever seen, and I know I'm going to get it out, and I'm always going to get it out without breaking the necklace, but I was going to be there a while, and again, probably a few cuss words, so do take your time, but the vasopressin is going to decrease that bleeding, and use a electrocautery, and anyone's been with me in the OR will say, you know, again, how big I am on using electrocautery, because you want the same benefits you use in abdominally, right, nothing changes because you bring your bovie or electrocautery into the vagina, it's sort of the same benefits, and using a needlepoint cautery, one of the best instruments you can have on your tray, when you're going to remove a mesh, or, you know, excise one, or modify exposure, is having a needlepoint cautery on it, and sometimes bending it to get a little better angle is going to be huge, I do tend to remove everything that's exposed, you know, all the material, and try not to leave anything behind, and I actually would go a little bit more, I'll show you some pictures, where I actually want to go a little sub epithelial, and dig out, and make myself a little collar under, you know, beyond what I can see, I want to dissect, and go a little bit beyond that, you don't always have to close the vagina, because, and I would advise not to do that, if it's going to be on any kind of tension whatsoever, and so to bridge large denuded area, and think about a, you know, a biograph, the thinner, the easier, I've used, you know, various products in the past, but again, something that's going to facilitate re-epithelialization, so here's a classic exam, it's case number one, this lady comes in, usual discharge, maybe some spotting, perhaps, you know, it's actually active, the husband is feeling something, patient's wife, they can feel something sometimes, or they're putting in their vaginal estrogen, they feel something rough, scratchy, you've heard those stories, and again, upon inspection, there you are, you're staring, and again, you can see here, it's hard to dimensionally, but again, this, this, this mesh is not breaking the plane, but yet, it's pretty big, it's bigger than one centimeter, so this is what I want to excise, even though you say, well, it looks pretty flat, and below the plane epithelium, maybe with a wing, and a prayer, and there's a messaging, you know, in months on end, it may re-epithelialize, it may, it's just, the juice ain't worth the squeeze on this one, right, it's just, the patient's going to be symptomatic for too long, not a happy camper, so just cut the mustard here, and take this out, it's not hard to do, so I start with infiltration, it doesn't show here on the slide, but it would take, you know, my basic, usually I use a quarter of a cent marking with epidephrine, that would be one-to-one with injectable saline, so there's no cardiac toxicity, despite ample volumes, so I'm going to be injecting, I actually want to put the needle right where the mesh is meeting the underside of the epithelium that surrounds it, so I'm going to inject right through there, 360, usually see something, I want to see some blanching, and then I'm going to put some traction with allicin here, and I'm going to use an electrocordery to go all the way around here, and underneath, you know, sort of rimming out underneath here, so that I'm not cutting right at the edge here, I'm actually trying to excise that mesh below this visual epithelium here, I'm actually want to cut that mesh back here under, and so I wind up with a lip or a rim of the vaginal epithelium over there, so here's the excised material, so now what I want to do is, I'm going to put some stay sutures in, they're going to help me hold my biograph in, now we're going to show you a picture, actually I'll just go ahead now, so notice how the artist's rendition from, you know, the marketing materials for this graph show the knots out here, see that, and you can see that the sutures are actually going through the epithelium, not that that's wrong or bad, but I would actually prefer to put my sutures under here, so what I've done is, I've placed these sutures, this is a two over three ovicle, these are going underneath this epithelium and grabbing, usually again, you know, subdermis, if you will, if you're thinking about skin, or into sort of lamia propia, maybe muscularis, maybe, maybe, but it's on the underside here, and then once I cut my graph to size, I'm going to tie, notice how you don't see knots up here, and the graph is being encouraged to stay under this epithelium, so this epithelium can begin to rejuvenate and sort of, you know, re-epithelialize right across this, and then close this, and this patient will tend to come back in four to six weeks, and I'm sorry, I'm editing this down for the 45 minutes. I didn't show how this patient came back in in six weeks and you can never ever tell she had exposure. And so it healed up quite quickly. This is another one, you can see it's not that big but it's breaking the plane of the epithelium. You know, again, you can't see 3D here, but it is, it's coming straight at you. And so this has got to come out. It's not gonna heal conservatively. Here comes that needle again. So we're gonna do our infiltration right along the edges. You can see the blanching, again, Corbusett marking using a smaller gauge needle. And then in comes my electric, you know, my electrocorticoid bovie tip, you need your extended tip if I'm reaching way up in the vagina. You can use a standard tip length and then feel free to grab a Kelly and gently bend it so that you get a good angle. And what I'm doing is you can see scoring underneath that, again, creating that lip there and then getting all of that material out of there. And then finally, there's a denuded materials out. And then I'm gonna, again, here's my, those, you know, try to read retention sutures, if you will, that are gonna sort of fixate my graft. And you can see I'm placing them once again below that epithelium. And then here we go, we can see my knots, not great here, kind of sticking out a little bit. Notice my knots aren't up here. And I found that this kind of approach, you can make an argument that doesn't look too clean right there. But again, these tend to heal quite well and patients, you know, come in with favorable responses. Here's a different kind of, you know, just shifting gears a little and you can have patients come back occasionally, I don't, almost rarely, because I'm kind of confident when I see a patient packed in that's had a vaginal mesh and they're not gonna come back with recurrent cystic fields, but they can. And whether it's, and sometimes the mesh didn't really kind of stay where you tacked it before tissue ingrowth, right? So, you know, what really keeps a material in place is tissue ingrowth. So it's invagination of fibroblasts and muscle cells into the macropores of the material. And if the patient, before that happens, minimal day 10, before you've even gotten reasonable, if that happens early on, when the patient gets up out of a chair, does something, you know, violent vomiting or coughing, who knows, they can actually move the mesh from where you may have, you know, sort of fixated or, you know, put some stabilization suture, usually at the UVJ or comparing your body. So you don't usually have meshes shift away or, you know, or dislodge or any way displace themselves from their arms that are securing them apically or laterally. It's usually at these midline distal locations. And so you can go back in, find it, and then, you know, again, do some dissection and then advance that graft up a little bit. And then you're gonna reattach it. And these are PDS sutures here. This is, it doesn't show here, but this is the urethra up here and the UVJ. So this was a distal separation of the mesh and recurrent distal cysticeal. Patient comes in complaining of a bulge. And even though there's not a lot of symptoms there, the patient's not happy because, again, she's aware of it. A lot of times patients are just concerned it's gonna get worse and worse and worse. And you just do the patient a big favor and say, listen, let me go back in and do a little touch-up surgery. And then the patient is gonna be very thankful and gracious. Here's that patient when it was done. You can see that, oops, sorry. You can see here, obviously, any kind of sense of bulge has been removed here. And all I did was, again, advance that, trim a little epithelium here and close that. And I made another management of it, you know, a complication or suboptimal with early mesh displacement prior to tissue invagination. So other kinds of, you know, things that I think about in my treatment is, do you suspect that there's any kind of bacterial overgrowth? And these patients tend not to get fulminant cellulitis or infections with an eye. No one spikes fevers, develops white counts, or has elevated SED rates. But you can tell there's some exudate. There is something going on, you know, at least on a microscopic level that may improve, you know, impede tissue healing and remodeling. So think about that. If you have a larger exposure, been there for a while, and there's usually some, you know, purulent exudate, white cells, and you know there may be some benefit of treating that before any kind of surgery. Wider dissections are better than smaller ones. So I go a little above and beyond when I'm removing mesh material, again, to mobilize and make sure that you've been along the edges. Because most of the time where I can tell patients have had something resected, there's a recurrence. It's usually around the margins. It's like cancer, it recurs at the margins. And whether you approach it in a vaginal versus abdominal, it's really going to be based on this location and what was the original placement, right? Abdominal grafts and meshes very often are going to require an abdominal approach to get to them. You can try vaginal, but that's a long way to drive to get the entire graft out, especially as it heads back towards the anterior longitudinal ligament sacrum. And again, most of my lecture here and most of my experience has been in vaginal access to address vaginal-based grafts. And again, some of those being of sub-midurethral slings. And it's the same concepts of a midurethral sling that we're talking about. The closure of the vagina, because it can be beneficial, don't be married to it. I don't think you have to do that. Don't do it if there's going to be tension on that closure. So if you've got enough tissue mobilized, you think you can close it, definitely if by chance you can do a multilayer closure with muscle, in addition to that great, that's usually not attainable, it is because of the amount of tissue you have left, because most of these exposures are happening because of being superficially placed. So if they're superficially placed, it's not a lot of layers to place over it, right? So that's rare that you'll have that opportunity, but you cannot do that. Again, another example, I remember this patient came in and unfortunately, even though she had a tiny exposure, I could tell the entire graft was too superficial. So I either could feel fibers here and there throughout her entire anterior vaginal wall, or I could almost see the macro pores below. I mean, it was paper thin. So even though only one area is exposed now to set your watch, it's just going to go here, here, here, here. And that's where you hear these people having multiple office space exposures, but you shouldn't ever go down that rabbit hole. I mean, you can sit there and say this entire graft that I'm looking at is too superficial. And even though you only have one exposure here now today, you're going to develop more and more and more. And unfortunately, this whole graft has to come out. And again, I'm very candid about why that has happened. It's not the mesh. It's actually the surgeon who didn't put it in correctly so that they don't spread evil, bad rumors about mesh and freeze patients and prohibit their decision-making, whether it's a slank or sacral copepectomy, but they get into the mindset that all mesh is bad. This is just showing stay suture. Now, what I'd like to do is put silks through the material because it's tedious dissection. And what you want to do is, like anything, traction, counter traction. Well, it's hard to get your eyes here and visualization with your fine instruments if you've got a big old Alice clamp right here and here. So what I found is the more you can put little tiny silk sutures, almost the more the merrier because they get different vectors, right? You can pull on them in different directions. You can sort of customize the counter traction you want. So it almost looks like, geez, could you possibly put any more sutures in there? And again, here, this is one that we're going after. This is more apical. There's a peritoneum small bowel. Here's the mesh here. You can see a bunch of silks that I put in to help me get traction, counter traction. So I'm able to see what I'm doing and get the nuances of the vectors of what angle I want to pull this on without my big fat hand being there or, you know, and again, if you are using an AdSense, it's limited. So this is, again, just using the stay sutures, getting mesh out. This is just patient where, again, you can see, you know, geez, Vince, did you possibly put any more stay sutures on there? It seems excessive, but it actually does help in helping you remove it. I'm not, you know, in this mindset that all mesh has to come out at all. I think if you've removed enough mesh to release it. And so if you have pain, it's usually due to bunching or excessive bulking of where if you put, you know, six centimeters of mesh dimensions into a three centimeter dissected field, well, something's bunching somewhere. And even ultrasound studies that have looked at immediately, post-operatively, again, the mesh isn't contracting. It can't blame the mesh and, you know, and sort of contractile elements that grow into the pores. And yes, mesh will contract. The polypropylene strands don't contract. The pores actually shrink because there's contractile elements that create that. But that, again, doesn't happen in recovery room. When you see that, it's poor placement due to suboptimal dissection, the lay mesh is flat, and proper, you know, trimming of the mesh at the time of placement so you don't have bunching. But that one had to come out in its entirety because of poor placement. And here's the closure. The patient did fine. Again, that same graph, you know, they are showing, sorry, same, you know, artist's illustration of showing the use of biograph if you need one. And here's another patient, again, who has that similar thing. I think that's a repeat. So I just want to step back a little bit before we go down the sort of, you know, complex thing of dealing with pain, and obviously pain with intercostal. And why is it? Because that's when the patient's moving, right? Very often I try to get patients to understand whether it's surgical site pain post-surgery, and it's usually due to scarring. And scarring creates, you know, traction or tethering of nerves that normally, you know, slide beautifully, right? So in this thumb here, never injured, never operated on. But how much I move it, it's always comfortable. And this thumb over here, I cut two tendons in that, or the surgeon could be a player, you know, by a hand surgeon. So if I don't move my thumb, they're kind of both equally comfortable. If I bend this thumb a little bit because there's scarring in there, it has to be, right? That's how tissue re-approximated incisions close themselves before there are sutures in doctors. There's a contractile element in tissue remodeling that when I do bend it, the nerves don't slide easily in lubricated sheaths or hoses, but they're starting to be tethered. And one way to activate a nerve is tether it or put traction on it, and it will fire. And then my brain says, well, that hurts. And if I really crank my thumb over. So I think spending some time with patients, and again, the vagina tends to move, you know, very much so during intimacy, sometimes with movements, whether it's getting out of a car, certain pelvic movements, there'll be some, but mostly it's with, you know, with intimacy. And this was looking at, do transvaginal mesh systems cause pain? And it's well done. I know the primary author who I know is a good surgeon. So very often when I look at, you know, mesh articles, I'm going to look at the author and I tend to know, or I'll dig and find out, are they good surgeons? Because if it's not, if it's not a good surgeon, it's almost not worth the paper it's written on. You know, call that crude or, you know, but it's true, right? So I know the surgeon, know she's good at it. And it's, you know, Doug Hale's group out there and the principal author, Troy Loman on this. And this was a good size of patients, only two attendings that know what they're doing. Looking at those patients sexually active reported dyspareunia before surgery. And again, looking at 36 patients for evaluation. The rate of de novo was 16%, which is very reasonable because you look at de novo dyspareunia after other prolapse surgery. Here's abdominal sacral complexity. And that's kind of, you know, the best. Why? Because it's an inline support system, right? Here's the vagina and on the, you know, on the sacrum, the mesh is in line. So when you, you know, when there's penetration, you push the mesh back towards its site of attachment. So it's an inline support system. I mean, that's 12 o'clock. So you can't beat that, right? So if you're on a cliff and you want somebody to pull you up, if they're 12 o'clock above you for every ounce of effort up the cliff you go, once you start moving off site and off 12 o'clock, whether it's a uterocycles or sacral spinus, that creates a little bit of an issue. So when the vagina is displaced, it's not correctly back towards it. So you can easily see how things change when you get off midline. When you look at sacral spinus, ligament fixation, uterocycle, those have looked at de novo post-operative. And again, you know, anterior and posterior repair, you know, a transvaginal mesh is right in line with all of those. It's nothing unique. Could you make the argument that some of these may be more refractory? Perhaps, but not necessarily. And so 94.7 answered true to the question overall. Overall, the transvaginal mesh surgery has improved my quality of life and I want to have this surgery done again. And that was something that was taken off of our SSQ-8, which is a satisfaction questionnaire looking at how do we do after surgery. And it's a short questionnaire and the two caveats on that questionnaire. If I could go back in time and do this surgery all over again, would I choose it or I recommend it to a friend or a relative? And those are very telling. And I stole those off of the other service industry or product industries. Like, would I go to a hotel again or recommend it? So I think they're good insight in the patients that I would have this surgery done again. And here's her little flow chart from that study. And again, you can see that more patients have resolution of preoperative. They're sexually active and they're having pain or they're not having pain. So these patients that have pain, we know there's discomfort with intimacy and at least also problems with self-esteem, body imaging. It's always hard to feel attractive. There's distention, collapse, and bulging of your vagina outside the introitus. And we looked at that through questionnaire. You can see a much larger percentage of patients had their dyspnea resolved and got new dyspnea. And again, it's actually very manageable. And most of the time we're looking at patients that, again, are they having pain? And certain factors before we even go down that road is looking at, you know, is their patient at high risk for de novo? Remember, patients that are in pain tend to stay in pain or pain gets worse. And that's any pain anywhere. It has to do with C-fiber activation and up-regulation of pain virus. And it's a whole pain gate therapy. Outside, you know, it's above my pay grade. Other people write those chapters, but I didn't know a little bit about it. And then understanding that the patient has had prior pelvic surgeries or has chronic pelvic pain from a host of conditions, there's a good chance that you're gonna make that situation worse with any surgery, mesh, no mesh. Young people, their nerves tend to work better than older people, right? Older people, they don't have as much sensory afferent function, so they're gonna not be as susceptible as younger patients. And then we did find in the surgeries that we've looked at in our own group here is that if they've had any other permanent suture material and or graft, and again, why is that? Well, anytime that you're using something permanent, you really need to be placing it ideally as perfectly as possible because there's no get out of jail free card with permanent materials. And so unfortunately, any suboptimal placement of a permanent suture or a permanent graft can come back to haunt you because of nerve entrapment and even over-tensioning, sling, you can't urinate, mesh, you have pelvic pain, there's over-tensioning, you're gonna wind up with pain. Mesh properties, yeah, way back in the day, and I always keep a really big, heavy hernia mesh on my desk from, I think the early 90s, I showed you how old I am, if not the late 80s. And this thing can stand on its own two feet and walk to the locker room. I mean, they don't make these anymore. These heavy weight and dense mesh, so good news. There's nothing that we currently use falls in under that category in today's day and age of material science and grafts. And again, remember, it's proper dissection. And today we're all still putting in slings. It's proper dissection, you can place the sling where you need it. And then finally, improper tensioning, right? Too tight, you can't urinate properly, you affect the emptying phase. And too loose, it doesn't really help. And so the more, I guess, the more science we put in that or technique we put in the tensioning, the better off we're gonna be. So all graft placement should be tension free and you have to anticipate some element of wound contraction. And since the mesh is in the wound, there's gonna be contraction. You can't put a mesh in the wound and not have it contract, right? That's kind of silly, right? Rectal pressure and discomfort, I think happens in a lot of patients where you can use graft to get around the rectum. I don't see that a lot with anterior vaginal mesh as long as there's a pressure discomfort. And again, sometimes with deprecatory function, you can be, again, affected with any kind of posterior scrapping. So when I look at any posterior grafts that have gone in and they're sort of arching down over the rectum, again, you can conceive how if it was over tension at the time plus wound contraction that now patients have chronic problems with deprecation, not regularity, not constipation, but actual deprecation. I have used neuropathic relief agents like Lyrican and Merotin to help, but I don't think they're good long-term. It's really to try to buy you some time as you get the patient some relief, as you kind of figure out your approach. Physical therapy is great. And for those who really have good physical therapists that know how to do myofascial release of any of the musculature knots that show up in the iliococcus or coccygeus or any of the vader-ani grouping, but that's gonna really be dependent on your physical therapist. So don't just say, oh, send the patient to physical therapy. Make sure you know who they're seeing. Is that patient good and have the skillset to do that, or you're wasting your own time. Again, there are things that you can do to help with pelvic muscular relaxation, vaginal suppositories. You've gotta have a compounding pharmacy that'll do that. Works quite well on patients. And then lastly, an off-label use of Botox, but I have done it. There's an article out there in our literature, and it's actually, it was presented at one of the Augs meetings. That's where I got it from. So another plug, shamelessly, to 10 Augs. You'll pick up tips and tricks at the meeting. That's where I got my technique of how to inject from Botox into the pelvic musculature was at an Augs meeting. And lastly, the one that I use quite often is injecting steroids. Matter of fact, I did it recently, two weeks ago, and today I got a text from a fellow from several years ago, how a patient was having chronic groin pain after one of her surgeries, and more often than not, groin pain is ilial, inguinal, and ligament injury that's sustained and not healed because no one recognized it. And so, Again, steroid injections into scars do what? They disrupt cross-linking of the scar. Scar will release. So if I have a painful scar on my face and I inject it, that scar is going to bigger. Not good for cosmetic areas. This is not a cosmetic area. So we don't care if our scar gets bigger. So again, I do steroid injections into palpable scar bands where I don't feel foreign body. So if I palpate an area that's painful, I can elucidate the pain on palpation. I'm saying to myself, is this contracted soft tissue? Is it a scar or is this foreign body? And I know the difference. It's subtle, but it's real. And sometimes you may not know the difference. And to be honest with the patient, listen, I can't quite tell if the firmness I hear and the loss of pliability and elasticity is scarring or is it your own tissue just scarred up or is it or is it foreign body? And so if I inject it, it will loosen the scar and soften it. And trust me, you get used to doing steroid injections into painful areas where surgery has been done, even episiotomy. You can alleviate a lot of pain for a scar release on patients. So it's sort of one of my favorite go-to things in my toolbox that a lot of people aren't familiar with and don't know how to do it or haven't done much of it. And obviously, if I'm going to go in for pain, I'm just going to release mesh. This idea of taking mesh out for pain is just not founded. There's not good evidence to support it in the literature. And in my experience, you're going to go off and do more harm than good by going after mesh that's there because somehow the mesh is releasing bad juju that causes pain. It really doesn't. But so I'm going to only remove as much mesh as I think I need to release any of the tensioning. Once I've released the tensioning, stop. No more excision is going to help that patient. More dissection is actually going to harm that patient. So here's our little instruments that we use for these deeper injections. And I have used also a neurolytic agent, so potassium-based. And you can get these from pain doctors of what cocktail is a neurolytic. It means it'll actually kill the nerve. You never start with that, right? You want to know. And I tell patients the nerve that's giving you this pain doesn't give you eyesight, smell, or sense of taste or anything. You don't really need that nerve. So I'll try to numb the nerve and see what kind of clinical response I get with transient marking. I use basically a spinal needle. I back up here. I'm sorry. I cut the tip off. So that's how about about a centimeter of my needle is going to come through there. So I cut the plastic trumpet with my long fingers, sort of get that right over the epicenter of the pain. And then here it comes. My cocktail is two cc's of Mark Kane, one cc of Deprimedrol for a three cc total volume. And I'm going to thread that needle right down over my hand into that area of pain and inject that. I usually, like baseball, you know, three strikes are out. If I've done that three times and each time the pain goes away and comes back, pain goes away and comes back, at least I know I've gotten to the area and I'll feel comfortable going in there the fourth time and injecting a neurolytic. And neurolytics are kind of like weed killers. It'll knock out the nerve quite well, but the nerve may regenerate and you may get some recurrence. But I'll always try these things before I surgically go after it. Because again, you know, going after it surgically, it's not a free lunch. When I do go after it with these injection therapies, again, the literature mixed messages, you know, conflicting data. Well, it's not, again, you have to be experienced at doing these things. When you talk to patients, they go, Dr. So-and-so injected it and it didn't work. You know, I'll just say, well, if you inject it on the floor, it won't work either. And I say that facetiously because with a needle, it counts. And no one's had more injections between my surgeon's elbow and my spine before I get operated on, had tons of needles stuck into me. And I had surgeons that were really good at it. And I got relief from those injections. And I had injections done by other docs that didn't help me at all. So I've lived through that, you know, where the bevel is matters. And you've got to be, you've got to have a certain expertise at doing it. So again, this is an article just throwing out there, just what you tell patients and what, you know, what you can expect. Again, you can see exposure treated successfully 95%. I think it can go even higher than that. I've never met an exposure to any cure, but this is the real challenge. It's painful treatment successfully. It's only half the time. So I'll go to, you know, the great lengths to try to treat pain from mesh before it excites it, unless I'm convinced on exam that I've got tension on a mesh arm or a mesh or a bunching. If I've got bunching or tension, I'm going in surgically sooner as opposed to later. If I can't appreciate bunching or tension, I'm going to try everything else first. This patient came to me, believe it or not, all the way from Alaska, crazy, dyspareunia. And as I got into this patient and started, because I thought really, you know, somebody between here and Alaska should be able to do this. But nonetheless, as I got in there, it was probably the worst case of bunched up, rolled up mesh I've ever seen. So mesh is like this inside a patient. This mesh didn't do this on its own. This didn't help. This didn't happen with tissue remodeling. This is, this was the way it was placed, right? It was not trimmed right. It wasn't sized right. It wasn't placed right. This is, when I see this, this is surgeon era to beat the band. And I felt, you know, they had complete relief. And this is her, you know, as we're finishing the repair, but she had complete relief. Just again, a video, sort of a photo montage here. And again, there's my stage sutures or traction sutures, I should say, to help remove it. This is the lady came in with, you know, after an elevator procedure, it was told that they can't get it out. She had, you know, some treatment and some surgical release, if you will. But if you don't go down to the level of grommet and really release where the site of the contraction, it's not going to help. So we tried some trigger injections, and it didn't work. So we took her to the opera room. And that was one of the hardest cases I did. But I was able to get both the anchor and the grommet out and the patient did. And she was a nurse actually had some complete relief. This last slide, I'll end it here. Medical legally, this is sort of a cut and paste from, you know, something I do with a bladder injuries, and ureter injuries, and they suddenly go part and parcel sometimes, always don't leave an OR unless you know for sure that your lower urinary tract's intact. It just isn't it takes two seconds. So I even though I'm, you know, good at what I do, I never not look into the bladder and make sure both bladder and ureter haven't been, you know, compromised by myself, always ask for help in any situation. No, no, let your ego check it out the door. And make sure you ask for help, whether it's you know, someone scrubbing with you or referring a patient. Again, I'm always a field club. You know, I feel privileged that I threw my years of context, I have a little black book of people smarter than me and better than me and some of these complication managements. And, you know, and I'll make sure I ask for help or send for second opinion. Be, be, you know, boldly honest, you know, you can't be too honest with patients or family about what's going on. It always comes back. They're very appreciated. Be diligent about, you know, achieving resolution. And don't, don't be good enough with some of these problems. Make sure you get the patient resolved. The sooner you do that, it's much better than later. And again, document, document, document. And unfortunately, some of the EMRs and things that we're using just don't have, I think, the white space to really be as granular as you can. But make sure you find a way in your system. Don't be, don't be restricted by your, you know, your landscape, your EMR, not to speak into the volume you need about what's happening with the patient. I think that's all I got. Yep. Another 47 minutes, not bad. Perfectly on time. Well, thank you very much, Dr. Lucente. We now have about 15 minutes for questions. And it looks like we already have two people that really have the same question, which is what kind of biograft are you using for these cases? Most of the time I'm going to use it, you know, I was using an L-sit a cell, a cell for a while, the graft, and there was a porcine graft. And now it's mostly a coloplast makes a dermis graft that I use. And those are the two products that I've used. And someone else said, or have you used alloderm for this? Yes, I have in the past. Yeah. Yeah. And, you know, my question, I was actually about that as well. Do you tend to put a biologic in every repair or are there certain circumstances where you feel like they need it? Yeah, mostly if I can't close, right. If I think it's larger than one centimeter, I cannot close it without tensioning. Then I'm going to, I'm going to quickly go to a graft and sort of bridge that gap where I don't have tissue to meet tissue. So that's, it's, it definitely fills in denuded areas where there's not, you know, not epithelium. And so, yeah, I'm, I'm, I have a low threshold to go to grafting because I think if you, if you try to go the other way, let's try to live without it. And you try to mobilize more tissue, even if you mobilize it, it's under tension, you know, beyond that. So I think you're, you know, more often than not, if you lean towards grafting, you're going to be better off than you leave. If you lean towards mobilization and closure. And then another question I had was, you know, you, the, the examples you showed were primary removal, primarily removing the transvaginal meshes that were used for prolapse. Is your approach for like your standard, like, you know, one centimeter mesh exposure in the middle of the mid urethral sling similar? You can probably, you know, again, if it's right where the incision is very often than not, it's just, you know, or, you know, closure and wound healing, and then just a hiss or something, it's right where you put it in. Then I would, you know, you could probably do less than that in terms of just, what I've done is just remove what you can see and call it a day. And again, we did a study on this and people that remain dry, it really kind of depends how much you take out, but a large number of them do stay dry for a while. See, this is the challenge, you know, we did this paper a long time ago, and about five years out, I think the coauthors were Charles Reardon and, you know, and Mary's Coley. And I mean, John Nicholas way back in the day, in their late mid nineties. And I, I'm still here in Allentown. So my patients come back to me like homing pigeons. And what I saw was, you know, five, seven, 10 years out, they had a much higher recurrence rate than patients that had, you know, meshes that slings that were never interrupted. So I think once you interrupt the sling, you kind of open up Pandora's box a little bit. I tell them they may, even though they're dry now, so you excise it and they stay dry, they go good, you're dry, you're going to stay that way. Yeah, not so much. And, you know, and thankfully, we have other options, whether, you know, it's bulking agents, you know, they can come to the rescue in some of these situations. And I'm okay with re-slinging patients 10, 15 years later. And I usually tend to pick a different sling. I don't like to put retropubics on top of retropubics, obturators on top of obturators, but you do have options, but I would tend to be more minimalistic approach to exposures with slings. Yeah. All right. We have another question, which is how do you treat urethral erosion? And I'm assuming what that patient, a person needs is that like erosion into the urethra as opposed to into the vagina. Yeah. So obviously that has to be resected. There's no real conservative management for that whatsoever, because they're going to create problems with usually stones even form on them and they'll get, you know, dysuria and painful voiding and UTIs. So again, that's very meticulous dissection. I usually identify the sling outside the urethra, dissect until I remove it. And then that one, by all means, you're going to have a multi-layer closure. And you may even use a Martius flap or vulvocavernosus muscle if the defect is that large. So each one is going to bring a challenge. But again, that's one where if you haven't done a lot and you're not confident with a, you know, capital C, like, yeah, bring it on, make sure you have people in the room that have some experience or expertise, whether you, and that's a great time to tag team with your urology colleagues, your female urologists in your institution. So there's got to be places, I have a great relationship, you know, here, and I always try to foster that no matter where I go. Really, it behooves for you and your patient to have a good collegial relationship with your urology team. If they have a little bit more familiarity, comfort zone with, you know, urethral surgery, then make sure they're with you. But it does have to all come out. You do have to reconstruct urethra, I will put a foliate of a smaller gauge and leave that for at least 14 days, if not longer. I guess your enemy there, you don't want your incision lines, your urethral closure incision to line up with your vaginal closure. So think about some advancement flapping, because your, your, your nemesis there, as you would imagine, is urethral vaginal official, right? And so you don't want any foreign body left around. You don't want overlapping suture lines. And you want to make sure there's good epithelialization or healing of the urethral lumen before you, you know, allow, you know, spontaneous voiding without a catheter. So a lot of precautionary there, but they need to be operated on. Great. Another question from our chat here is, do you still place synthetic mesh on recurrent prolapse cases? Yes. In terms of do I still do it vaginally? No, because of the legal climate we're at. And so I will do that, you know, obviously abdominally. And then the next question is, you know, I think you can, you know, when, when mesh came off the market, transvaginal mesh, I had to scramble and have a good, you know, transvaginal, you know, alternative. And so I gravitated to using some biograft that's reinforced polypropylene threads. So I run polypropylene threads arm. So I create, you know, sort of synthetic arms on biograft bodies. All right. So in the arm of the biografts, I'll run proline through the attachment site, usually obviously sacrospinous ligament, and then run that proline all the way up to cervix or cup. So I've got proline arms, because again, most recurrences are detachment, not distension, right? The Lancey has told us from root cause analysis that it starts apically, works its way laterally, both in terms of detachment. And then lastly, through distension of the fibromuscular tubing of the vagina, mostly longitudinal. So if you can reestablish apical reattachment with something synthetic, so I always say the patient's meshes were made by taking two filaments and knitting them to make a fabric. Well, if you take heavy gauge filaments and actually just sort of replace those as synthetic ligaments, patients do quite well. We've published and presented on that, but actually mesh in itself, obviously it's just not feasible in today's day and age, given the legal climate where the FDA is gone and even our own society. Again, it's not a good thing. I think it's a shame. It's beyond the scope of this lecture and talk about the trials and tribulation of the mesh story, but it's more a story of surgical training and suboptimal physician education and with new products as it is as bad product. Next question is what are the exclusion criteria for using a synthetic mesh? Almost none, if you will. No, absolute. I mean, so there's nothing that, you know, and I actually had one today, so there's an exclusion criteria. She heads up the support group and the anti-mesh. So when people are just sort of grounded and talking to Pat Culligan, because he actually sent me the patient, I said, thanks, Pat. That was wonderful. And I said, well, what are you going to do? I said, I'm going to have a candid conversation with her that the therapeutic relation between her and I is just never going to work. We're on different pages about how we think about using mesh or polypropylene. So the only absolute exclusion is someone I have determined is absolutely convinced beyond any shadow of anything that mesh is bad for them. And I'm not going to find a way to talk them into it. It's just not going to go there. I guess the other thing is that someone has a history of hyper reaction. So there's people called hyper responders, right? It's an allergic type, you know, response, if you will. And again, outside of my wheelhouse, they tend to have an allergy list about this long. And some of those things are going to be plastics and are called hyper responders. So if someone has a big history like that, I may be suspect we've gone as far as it takes polypropylene, tape it to their arm and hypoallergenic and look to see if we see a real reaction to it. So there's some subtleties of where I'll be shied away from it. But for the most part, you know, I'd say there's no patient where I'm going to say absolutely, there's no way of I would recommend mesh. And you know, that's not been my experience at all. And so it's rare that I'll say that this patient is not getting mesh. I'm not going to do it. And it's very few times. Next question is, how do you prevent ureteral injuries when dissecting the arms of the mesh? Do you use stents? I would say rarely I use stents. And again, if you stay if you take if you get to an arm, and you stay on the arm, right, and so unless that arm is compromising, if you think that, you know, the patient has, if you think the arm is compromised in the ureter, then you're in, you're in danger zone, you're in the red zone, most of the time, it's not. So the trick is not to wander off the arm. Right? So that's why stay on the mesh, hug the mesh. That's why those traction sutures are there. It behooves you to not wander off that material. And then three dimensionally, right? So don't make sure your scissors go wide or off the arm, especially if you see them tracking in a way they should be tracking down in a way, right? It shouldn't be midline and tracking midline. And I've seen, you know, one of my most difficult cases where I did call an oncologist in to help me. It was the one time of my life, actually two, I just lied. Two times I've called oncologist in the middle of surgery to help me Mr. Wizard. And one of them was a arm tracking into Never Neverland. And in the oncologist said, Vince, I like you a lot, but don't ever call me in your OR ever again, because the two of us were sweating bullets to get that out. So always be heads up about it. I don't find it to be all that common that I'm worried about your retal. So I'm not a big step placer guy. I'm thinking about, you know, kind of careful dissection and knowing your anatomy. Great. Well, it looks like we addressed all the questions. On behalf of AUGS, I'd like to thank Dr. Lucente and everyone for joining us today. Our next FPMRS webinar is going to be on October 20th at 7 p.m. Eastern Time. And you can visit the AUGS website to sign up for that. Thanks, everybody. And thank you, Dr. Lucente. Have a great evening. Have a good evening.

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mesh complications

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biologic grafts