(WS 26) Management of Complications From Trans...
Transcript of (WS 26) Management of Complications From Trans...
(WS 26) Management of Complications From Trans-vaginal Mesh:
TREATMENT ALGORITHM
IUGA 41st Annual MeetingAugust 3, 2016
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Management of Complications From Trans-vaginal Mesh:
Learning Objectives
“At the end of this lecture, the learner will be able to…”.
• Describe the Scope of Complications from Trans-vaginal mesh
• Review the literature on management of complications
• Define an evidence informed treatment algorithm
Disclosure
I have the following relationships that could provide the perception of a conflict of interest:
• Research grants: – no direct corporate grants
• Speaker’s Bureau: – none
• Consultant:– Expert witness for defense in malpractice cases
• Investment: – none
Levels of Evidence• Level I: Based on RCTs *
• Level II-1: Cohort or case-control study *
• Level II-2: Comparisons between times and places with or without comparison*
• Level III: Opinions of respected authorities, descriptive studies, case reports
• Level 0: no evidence
*(at least 1 and well designed)Canadian Task Force on Periodic Helath Examination Can Med Assoc J 121(9) 1193-1254.
The morbidity and treatment of sling erosions vary significantly from procedures for POP using mesh.1-3 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
The management of sling complications should be stratified by presenting symptoms.3,4 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Voiding dysfunction immediately after surgery should be treated promptly with sling lengthening or release.5-7 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Voiding Dysfxn Persistent SUI
Immediate Release
Later presentation should be evaluated with Urodynamics (UD).8(III)
Patient presents with mesh complication
Mesh used for MUS
Functional Failure Erosion
Voiding Dysfxn Persistent SUI
Delayed UDImmediate
Release
Sling release or incision is preferred to partial or complete removal.3 (II-2)
Patient presents with mesh complication
Mesh used for MUS
Functional Failure Erosion
Voiding Dysfxn Persistent SUI
Delayed UDImmediate
ReleaseSling Release
Delayed sling release has a success rate of ~40%, with better results in younger patients(OR = 3.2), and those
without symptoms of OAB (OR = 3.1). 7 (II-2)
Patient presents with mesh complication
Mesh used for MUS
Functional Failure Erosion
Voiding Dysfxn Persistent SUI
Delayed UDImmediate
ReleaseSling Release
Persistent USI should be evaluated with UD and a dynamic ultrasound to guide therapy.9(III)
Patient presents with mesh complication
Mesh used for MUS
Functional Failure Erosion
Voiding Dysfxn Persistent SUI
Delayed UDImmediate
ReleaseUD Dynamic US
UD parameters do not predict outcome.10(II-1)
Office treatment of erosion rarely works.2,3,11(III)
Patient presents with mesh complication
Mesh used for MUS
Functional Failure Erosion
Office Mgmt Surgical Mgmt
Trimming + EstrogenRarely works
Erosion by it self, can be treated with excision of
mesh to the point of tissue in-growth, and epithelial closure.3,11(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Office Mgmt Surgical Mgmt
Trimming + EstrogenRarely work
Excision & Closure
Transurethral or endoscopic treatment in the urethra and bladder is often successful and less invasive.12-
14(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Office Mgmt Surgical Mgmt
Trimming + EstrogenRarely work
Excision & Closure
LUT Erosions
Endoscopic: may work, less morbid
Cystotomy or urethrotomy, excision and closure may be more effective.15(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Office Mgmt Surgical Mgmt
Trimming + EstrogenRarely work
Excision & Closure
LUT Erosions
Endoscopic: may work, less morbid
Radical excision more effective
Erosion with pain, should be managed as for pain.3,11(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Office Mgmt Surgical Mgmt
Trimming + EstrogenRarely work
Excision & Closure
LUT Erosions Erosion & Pain
Pain usually includes a component of Levator Ani
Spasm. Consequently, all patients should pursue pelvic floor PT pre & postoperatively.16(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Functional Failure PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PT
Pelvic pain, including groin pain from TOT, should
be treated with division of the vaginal portion of the sling.17(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PTVaginal Sling
Division .
There is limited evidence, that complete removal of
the vaginal wall portion of the sling provides better
outcomes then partial removal, but with greater complications.3,18 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PTVaginal Sling
Division/Extirpation
Excision of sling arms, (legs or retropubic), generally
doesn’t impact symptoms, and is not without
morbidity. Reserve for patients with inflammatory response to the mesh material.18(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PTExcision of sling arms
Vaginal SlingDivision/Extirpation
Persistent pain may be due to obturator nerve entrapment. While MRI and EMG are not diagnostic,
improvement with injection of local anesthetic supports the diagnosis. Early complete excision is indicated.19 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PTExcision of sling arms
Vaginal SlingDivision/Extirpation
Vaginal excision has a recurrent SUI rate of ~20-36%.3,18(III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
PainErosion
Ambulatory Mgmt Surgical Mgmt
Pelvic Floor PTExcision of sling arms
Recurrent SUI ~20-36%
Vaginal SlingDivision/Extirpation
For POP procedures, management differs based on whether mesh is placed trans-vaginally (trocars or loose graft), versus sacral colpopexy.3,20 (III)
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Sacral ColpopexyTrans-vaginal
Diagnostic Ultrasound is the best modality for imaging mesh, and has been shown to be more accurate than exam.21 (III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Diagnostic U/S
Preferred Imaging Better than Exam
There is no compelling evidence to support a peri-operative role for ultrasound. (0)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Preferred Imaging Better than Exam
Diagnostic U/S
Peri-operative benefit not shown
The management of POP mesh complications should be stratified by presenting symptoms.3,4,22 (III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Management of isolated recurrent POP should not use additional trans-vaginal mesh or grafts.22(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Avoid trans-vaginal mesh & grafts
Vaginal excision for erosion and pain has a
recurrent POP rate of ~10-15%.3,23 Concurrent native tissue repair is recommended.24(II-2)
Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain
Avoid trans-vaginal mesh & grafts
Concurrent native tissue
Office treatment of erosion rarely works.2,3,11(III)
Trimming + EstrogenRarely works
Office Mgmt Surgical Mgmt
Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain
Excision & Closure
Erosion by it self, can be treated with a small
excision of mesh to the point of tissue in-growth, and epithelial closure.11(III)
Trimming + EstrogenRarely works
Office Mgmt Surgical Mgmt
Sacral Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Excision & Closure
Endoscopic treatment of mesh in the urethra and
bladder generally is insufficient. Cystotomy or
urethrotomy, excision and closure seems to be more effective.15(III)
Trimming + EstrogenRarely works
Office Mgmt Surgical Mgmt
Sacral Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
LUT Erosions Radical excision more effective
Endoscopic: may work, less morbid
Erosion & PainExcision &
Closure
Erosion with pain, should be managed as for pain.3,11,22(III)
Trimming + EstrogenRarely works
Office Mgmt Surgical Mgmt
Sacral Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
LUT Erosions
Because pain almost always includes a
component of Levator Ani Spasm, all patients
should pursue pelvic floor PT pre and post operatively.16(III)
Pelvic Floor PT
Ambulatory Mgmt Surgical Mgmt
Sacral Trans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Vaginal Extirpation
Pelvic pain, including groin pain, should be treated
with division of the vaginal portion of the mesh and
complete removal of the vaginal wall portion of the mesh.11,22,25(III)
Pelvic Floor PT
Ambulatory Mgmt Surgical Mgmt
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Vaginal Extirpation
PudendalRelease
Pudendal neuralgia should be considered in patients with mesh arms in the SSL.17(III)
Pelvic Floor PT
Ambulatory Mgmt Surgical Mgmt
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Hispareunia Loss of TissueDyspareunia
Sexual dysfunction can relate to dyspareunia, hispaerunia, and loss of tissue.22,26(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Recurrent POP Erosion Pain Sexual Dysfxn
Hispareunia Loss of TissueDyspareunia
Hispaerunia is generally cured with successful closure of an erosion.27(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Pain Sexual Dysfxn
Pelvic Floor PT
Hispareunia Loss of TissueDyspareunia
Sexual dysfunction can relate to LAS, and postop patients should pursue pelvic floor PT.16(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Pain Sexual Dysfxn
Pelvic Floor PTVaginal
Extirpation
Hispareunia Loss of TissueDyspareunia
Sexual dysfunction can relate to the mesh, so
division of the vaginal portion of the mesh and
complete removal of the vaginal wall portion of the mesh may be appropriate.22(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Pain Sexual Dysfxn
Pelvic Floor PTVaginal
Extirpation
Hispareunia Loss of TissueDyspareunia
Pudendal neuralgia should be considered in patients with mesh arms in the SSL.17(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Pain Sexual Dysfxn
PudendalRelease
Vaginal Extirpation
Pelvic Floor PTVaginal
Extirpation
Hispareunia Loss of TissueDyspareunia
Reconstructing the vagina in those with loss of
tissue is more effective when all mesh is
removed.(0)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Pain Sexual Dysfxn
PudendalRelease Flap
Graft
The most common mesh complication after sacral
colpopexy, is erosion. Vaginal pain is uncommon.
Low back pain due to osteomyelitis or discitis is
much rarer.28-30(III)
Sacral ColpopexyTrans-vaginal
Patient presents with mesh complication
Mesh used for POPMesh used for MUS
Erosion Low Back Pain
Vaginal erosions should initially be managed with
partial excision and partial colpocliesis, with or
without vaginoscopy, which is curative in 50% of
cases.3,31-33(II-2)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Failed cases should be managed with complete
extirpation by laparotomy. Morbidity is high.31,33(II-2)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Extirpation by Lap
Manage visceral erosions by Lap
Visceral erosions should also be managed by
laparotomy. Morbidity is high.(0)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Extirpation by Lap
Manage visceral erosions by Lap
MRI is the preferred imaging modality for
osteomyelitis and discitus.34(III)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Extirpation by Lap
MRI
Prolonged IV Abx
Manage visceral erosions by Lap
Osteomyelitis may respond to prolonged
parenteral antibiotics.29(III)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Extirpation by Lap
MRI
Prolonged IV AbxOrthopedic
debridement
Manage visceral erosions by Lap
Patients who do not respond will require
orthopedic debridement.30,31(III)
Sacral Colpopexyvaginal
Patient presents with mesh complication
Mesh used for POP
Erosion Low Back Pain
Partial colpocliesis
Extirpation by Lap
MRI
References
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2. Nguyen JN, Jakus-Waldman SM et al. Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants. Obstet Gynecol. 2012 Mar;119(3):539-46.
3. Ozel B, Minaglia S, et al. Treatment of voiding dysfunction after transobturator tape procedure. Urol 2004 Nov;64(5):1030.
4. Carr LK, Webster GD. Voiding Dysfunction Following Incontinence Surgery: Diagnosis and Treatment With Retropubic or Vaginal Urethrolysis. 1997 Mar;157(3):821-3.
5. Hoon AJ, Bae JH, Lee JG. Incidence and Risk Factors of Postoperative De Novo Voiding Dysfunction following Midurethral Sling Procedures. Korean j Urol. 2009 Aug;50(8):762-6.
6. Hedge A, Davila W. Multi-compartment Imaging of Slings.
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14. Jonsson FunkM, Visco AG, Weidner AC, Pate V, Wu JM. Long-term outcomes of vaginal mesh versus native tissue repair for anterior vaginal wall prolapse. IntUnrogynecol J. 2013 Aug;24(8):1279-85.
15. Brubker L. Editorial: partner dyspareunia (hispareunia). IntUrogynecol J Pelvic Floor Dysfunct. 2006 Jun;17(4):311.
16. Jeffrey ST, Nieuwoudt A. Beyond the complications: medium-term anatomical, sexual and functional outcomes following removal of trocar-guided transvaginal mesh. A retrospective cohort study. Int Urogynecol J. 2012 Oct;23(10):1391-6
17. Tsia-Shu Lo, Yiap Loong Tan, et al. Clinical outcomes of mesh exposure/extrusion: presentation, timing and management. Aust NZ J obstetGynecol 2015 Jun; 55(3):284-90.
18. Nygaard IE, Cundiff GW et al. Abdominal Sacral Colpopexy: A comprehensive Review. Obstet Gynecol 2004, 104:805-23
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21. Quiroz LH, Gutman RE, Fagen MJ, Cundiff GW. Partial colpocleisis for the treatment of sacrocolpopexy mesh erosions. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Feb;19(2):261-6.
22. Nosseir S, Kim Y, et al. Sacral osteomyelitis after robotically assisted laparoscopic sacral colpopexy. Obstet Gynecol; Aug 2010;116(2):513-5