On a recent audit of my practice 274 women have undergone vaginal mesh removal surgery between 2010 and 2017 at the Wesley or RBWH. These include problems after mid-urethral slings (Tapes) for urinary incontinence or transvaginal meshes for prolapse. Many of these referrals are from around Australia.
I have been involved in the management of mesh complications for many years with my first publication on the removal of vaginal tapes (IVS Distress 2005) and transvaginal mesh kits (Vaginal Mesh Contraction: Definition and Management 2010), both in the leading peer reviewed journal (Obstet & Gynecol: No. 1 ranked Journal for O&G). We also published the first randomised controlled trial comparing transvaginal mesh with abdominal interventions that was conducted right here in Brisbane and demonstrated significant complications and re-operations associated with transvaginal mesh products (Laparoscopic vs Vaginal 2011).
Problems experienced include:
- Vaginal, groin, urethral, rectal or suprapubic pain
- Vaginal bleeding or discharge secondary to mesh exposure
- Pain intercourse (dyspareunia) or pain for partner (hispareunia)
The cause of the pain associated with transvaginal mesh for prolapse is reported at rates of 3-8%. This is usually due to contracture of the mesh body (between 40-80% reduction in size over 3-4 years) where the mesh arms are fixed and come under increased tension as the mesh body contracts. I have always felt this was the cause of the vaginal pain and thus success we have reported with the removal of the mesh body and division of the arms. The following animation demonstrates this theory.
Tapes that have eroded into the vagina do not usually require full removal as seen in the video below. Following partial removal of the exposed tape the painful intercourse and vaginal discharge settled and this lady remained continent!!
Tapes that are causing pain may need to be fully removed. Retropubic tapes are usually removed laparoscopically with vaginal incisions.
Obturator tapes that are causing pain are difficult to fully remove but as seen in this photo can be fully removed. This surgery is performed through a combination of a vaginal incision where the tape is mobilised between the pubic bones and 6-7cm incisions in the groin to remove the full mesh.
This procedure is easiest if partial removal of the obturator tape has not been undertaken previously. There is risk of ongoing pain despite removal of the mesh and risk of bleeding, infection and recurrence of incontinence associated with the surgery to remove the tapes.
Finally Mini-slings are the easiest removed but care must be taken to also remove the anchors.
A tape that is eroded into the urethra as seen below can be partially removed or if preferred the full tape can be removed and this needs to be discussed with Associate Professor Maher.
This video shows the removal of the right arm of the retropubic tape that was causing right sided pain only. Partial targeted removal was beneficial in this case as the pain was resolved with the removal of the right arm of the tape and the continence was retained!!
Transvaginal mesh may need partial removal for erosions into the vagina.
Transvaginal mesh that have eroded into the bladder are usually removed laparoscopically and will require a catheter after the surgery for a week to ten days to drain the bladder as seen in the video below.
Transvaginal mesh that has traversed the rectum has also been removed as shown.
Transvaginal mesh that has not eroded into the vagina, bladder or urethra can still be painful and cause pain at intercourse and can be removed laparoscopically or vaginally.
In this case the peritoneal portion of the PIVS mesh is removed laparoscopically. Patients need to be aware that despite removal of the mesh at least one in three women will experience ongoing pain and only about one in three will have complete resolution of the pain.