Avoiding and Managing Mesh Complications after Surgery for Incontinence and Prolapse

1. Avoiding and Managing Mesh Complications after Surgery for Incontinence and Prolapse M Karram MD Director of Urogynecology The Christ Hospital Voluntary Professor of Ob/Gyn University of Cincinnati

2. Learning Objectives • Review appropriate techniques for sling placement • Discuss avoiding and managing intra-operative complications • Discuss diagnosis and management of postoperative complications • Discuss indications for current use of mesh in prolapse repair • Review how best to manage mesh complications

3. Types of Synthetic Midurethral Slings • Retropubic • Pre-pubic • Transobturator • Single incision mini slings • Home made slings

4. Intraoperative Complications • Bleeding • Injury to Bladder • Injury to Urethra • Injury to Nerves • Injury to Bowel

5. ANATOMY OF THE ANTERIOR VAGINAL WALL • Relationship of anterior vagina to posterior urethra • Distinguishing mid from distal urethra • Understanding lateral attachments of urethra and bladder

8. Anatomy of Anterior Vagina

9. ANATOMY OF RETROPUBIC SPACE • Anatomy of Bladder and Urethra • Vascular Anatomy • Potential for Bowel Injury • Anatomy of Anterior Vaginal Wall

17. TVT with bladder perforation

18. Rinehart; calculi

19. Transobturator Approach Anatomy of obturator foramen

20. Obturator Canal Ilium Obturator Foramen Ischiopubic Ramus Pubic symphysis Ischium

21. M. OBTURATOR INT M. OBTURATOR EXT

22. Obturator Foramen • Covered by a tough membrane that is continuous with periosteum and tendinous attachments • The obturator membrane covers the obturator muscle • Obturator canal (sometimes referred to as the fossa) is 2 - 3cm long, beginning at anterolateral opening of membrane • Canal is transversed by obturator nerve, artery and vein, vessels pass downward into the thigh

23. Obturator Foramen • Obturator muscles: • The medial adductor compartment - all innervated by obturator nerve • adductor longus, brevis and magnus • gracilis and pectineus muscles

24. Obturator Foramen • Obturator vasculature: • Obturator artery passes through obturator canal and divides into medial and lateral branches • Upon entering canal, divides into anterior and posterior • Anterior branch innervates adductor longus, brevis and gracilis

25. Transobturator Landmarks Adductor longus Urethra Obturator canal SAFE ENTRY ZONE of TRANSOB NEEDLE

26. Needle entry & path

27. Transobturator Anatomy Anterior Vagina

28. Complications of Synthetic Slings • Postoperative complications Voiding Dysfunction Irritative Symptoms Trade in Prolapse MESH COMPLICATIONS Pain Recurrent UTI’s

29. Eroded OB tape

30. Eroded TVT; urethrovaginal Fistula

31. TVT SECUR in Urethra

32. Surgery for POP; What is the Future? • Prevelance will continue to increase • Will kits and mesh become standard of care? • Less invasive durable repairs will be developed • Increased understanding between functional derangements and anatomic descent

33. Master Class;Ob/Gyn News • In US from 2005 to 2007 a reported total of 994,890 surgeries using industry driven mesh were performed • The impetus for mesh usage was based on the FACT that conventional pelvic floor prolapse repair has an estimated failure rate of 30% to 50%

34. ↑ $$ ↑ Morbidity ↓ Prolapse Recurrence?? Mesh Kits

35. Hiltunen R, et al. Obstet Gynecol. 2007 RCT of Mesh vs. No-Mesh for Cystocele Repair,cont. • Mesh group: lower PVRs; higher de novo SUI (10% after anterior repair vs. 23% after mesh). • 18 of 104 (17.3%) mesh exposures; only 4 were symptomatic. 10/18 had resection; 7/18 had persistent exposure at 12 months. • Reoperations (mostly TVT): 6.2% in anterior repair group and 4.8% in mesh group (p=NS).

36. Use of mesh, especially polypropylene, in the transvaginal repair of anterior and posterior vaginal wall prolapse results in vaginal erosion, with associated bleeding, drainage and dyspareunia, in 5% to 17% of cases. Some cases are asymptomatic and some only need trimming but re-operations can result. Vaginal pain however is a particular and new concern. Serious Delayed Complications with Mesh in RPS

39. Mesh Erosion; vault suspension

40. Mesh in Rectum

41. G Fields

42. Mesh removal after vaghyst

43. Quote • “There is no condition or disease that cannot be made worse by surgery”. Ulf Ulmstem