Approximately 30% of patients undergoing pelvic reconstructive surgery will require re-operation sometime in their lifetime. In an effort to improve surgical outcomes, the use of multiple biologic and synthetic graft materials have been introduced. Most mesh complications will occur within the first year of surgery, though they may also occur many years later. Presenting symptoms include vaginal bleeding, persistent vaginal discharge, vaginal pain or dyspareunia, and voiding dysfunction. It is prudent for the pelvic surgeon to be familiar with the various presentations of mesh complications and their management. Mesh complications may present in different forms. Exposure of mesh may occur simply due to wound breakdown. Complications and symptoms may also occur when mesh is not secured or laid flat prior to re-approximation of the overlying vaginal mucosa. Trans-obturator needles used in prolapse kits and slings have a documented increased risk for vaginal perforation, which may go unnoticed at the time of surgery. Bladder perforations or erosions of mesh slings into the bladder or urethra have also been reported primarily with retropubic sinus. When conservative measures fail, knowledge of the sling material is important. Type I macroporous monofilament mesh is quickly incorporated into surrounding tissue. This property makes excellent functional outcomes but may make the material difficult to remove. Because of the low infection rate associated with Type I mesh, it is usually not necessary to excise the entire mesh in the case of simple healing abnormalities. In this case of a simple sling erosion without obstructive symptoms, the exposed Type I polypropylene mesh is grasped with a tonsil clamp and simply excised at the exit point in the mucosa. The mucosa may then be over-sewn if necessary for hemostasis. When mesh exposure in the lateral vaginal sulcus following trans-obturator needle passage, a through-and-through mesh perforation is identified. Simple excision of the sling material at the vaginal mucosal edge is performed in a similar fashion as these will be unlikely to respond to local estrogen in time. Patients who present with obstructive symptoms following an over-tensioned sling will require location of the urethral stricture. This can be facilitated with the use of a Hagar dilator. Once the point of stricture is located, the overlying mucosa is incised as in an enterocle porophyllum. Urethralysis is then performed taking care to isolate the mesh from the urethra without causing iatrogenic urethrotomy. Once the mesh has been isolated from the periurethral fascia and grafted with a tonsil clamp, the mesh can be mobilized with metsovom scissors from the puboscervical fascia out to the inferior pubic rimline and excised. There is rarely a need to dissect further as vital neurovascular structures lie beyond this point. In the case of erosion into adjacent structures such as the bladder or urethra, thorough cystoscopic survey is crucial. Electrocautery may be used to obtain hemostasis of the bladder mucosa. When infection is present, such as with type 2 or type 3 mesh, it is prudent to excise as much of the mesh as possible without causing iatrogenic injury. These types of mesh have been reported to present with remote recurrences and the development of draining sinuses from recurrent infection. In this case of a type 3 mesh erosion, the sling is often unincorporated because of encapsulation. The bacteriologic film coating allows for easy removal with only gentle traction. This can be facilitated with gentle spreading of the puboscervical fascia along the mesh arms to decrease friction forces, thus allowing the mesh to be removed in its entirety. Proper placement of vaginal mesh to augment prolapse repair is important as well. Mesh that is not securely laid flat and tension free to allow for tissue ingrowth may roll up or become bunched causing significant pain issues. This is a case of a simple appearing central erosion of synthetic mesh along the posterior vaginal wall. Upon dissection, a bunched up roll of mesh is identified and requires a wider resection than anticipated. The endopelvic fascia was poor to begin with in this patient and in spite of the excellent support that the mesh is providing, it was necessary to excise a large central portion. The resected gap in the mesh is then bridged with permanent suture to maintain posterior wall support. Although surgeons are becoming skilled with the placement of grafts, it is necessary to be aware of the management of their complications including graft revision and excision and to what extent this should be performed.

pelvic reconstructive surgery

re-operation

biologic graft materials

synthetic graft materials

mesh complications