Hypothesis / aims of study
Complications associated with mesh for treatment of pelvic organ prolapse(POP) and stress urinary incontinence(SUI) are well recognised. A number of these require surgical management for perforation into the urinary tract(UT). With limited published data regarding management of these, this project reviews management mesh-related UT injury within our service.
Study design, materials and methods
A retrospective cohort study of prospectively collected data between 2018-2023 was carried out. Patients were identified from unit databases. All data was collected from electronic notes including demographics, implant, site of perforation, management and outcomes.
Partial removals involved complete removal of vaginal portions of the mesh vs total removal where entire implant removed.
Results
25 patients were identified over this time period with UT mesh perforation during cystourethroscopy.
Mean age at referral was 59yrs(range 39-82yrs) and mean BMI 27(range 18-34).
Commonest presenting symptoms were recurrent UTI (48%), pain (32%), incontinence (32%) and voiding dysfunction (12%).
20 (80%) were mid-urethral tapes(MUT), 2(8%) were transvaginal mesh(TVM), 2(8%) were a sacrocolpopexy(SCP) mesh and 1 patient(4%) presented with a cervical cerclage Mercilon tape perforation.
84%(n=21) of patients had single implant, 16%(n=4) had multiple. Most implants(76% : n=19) were MUT, 4%(n=1) had both MUT & TVM’s, with 16%(n=4) having POP mesh only.
50% of MUT perforations were urethral (same for both RP and TOT), as opposed to TVM where all involved the bladder. Patients with MUT complications were younger (mean age 57yrs vs 78.5yrs).
16%(n=4) of patients had prior mesh revision before referral which included either laser or burying of exposed mesh.
12%(n=3) patients declined further treatment due to successful conservative management. To date 71%(n=17) patients have undergone surgical treatment. From these 47%(n=8) opted for minimal access surgery (laser), the remainder undergoing formal surgical revisions (partial/total).
20%(n=3) patients with bladder perforation opted for laser therapy versus 13%(n=2) for partial removal and 27%(n=4) total (remainder not yet had treatment). In comparison, 50%(n=5) with urethral perforation opted for laser versus 10%(n=1) for partial and the remainder awaiting treatment.
Comparing MUT and POP mesh, intervention rates were as follows: laser 40%(n=8) vs.0%; partial 15%(n=3) vs.0%; total 10%(n=2) vs. 50%(n=2) and nil treatment to date 35%(n=7) vs 50%(n=2).
Of the patients who had laser therapy(n=8), 63%(n=5) required either further laser treatment or proceeded to definitive surgery. All patients opting for total removal were under 65yrs. All patients over 75yrs opted for no surgery or partial removal only, avoiding more extensive total removal.
Formal Surgical group removal: 18% were partial removals/35% total removals (Figure. 1).
Of those undergoing laser treatment, 2 patients(25%) stated they were satisfied with outcome when asked comparing with 100% partial(n=3) and 75% total removal(n=3).
Interpretation of results
Patients who had laser treatment were more likely to require further surgery than those undergoing formal surgical excision. More patients with RP tapes opted for total removal, but numbers of patients were smaller so this needs cautious interpretation.
Previous surgery didn’t appear to be influencing procedure choice, however, did seem to make patients less likely to opt for no treatment. Age was an influencing factor.