TEMPLATE DESIGN © PROTRUSION OF A TENSION FREE MESH: A RARE COMPLICATION OF POSTERIOR REPAIR AND VAULT SUSPENSION Dr A. Au Yeung, Dr. O. Al-Baghdadi, Dr. A. Samarasinghe, Dr. B. Fathulla, Mr Atalla Lister Hospital, East and North Hertfordshire NHS Trust, United Kingdom Pelvic organ prolapse occurs when one or more pelvic organs herniate from its normal position or attachment into the vagina causing a downward displacement of the vaginal wall. Treatment of prolapse depends on the severity of the prolapse, its symptoms, the woman’s quality of life and preference. The incidence of pelvic prolapse is difficult to determine as many women do not seek medical advice. A broad estimate suggest that 50% of all parous women lose pelvic floor support and have some degree of prolapse with only 10-20% seeking medical aid [1]. This case report is a commentary of an interesting presentation of persistent rectal discomfort and bleeding after mesh repair for vaginal wall prolapse. CASE PRESENTATION REFERENCESREFERENCES In the recently reported case from Japan by Taoka et al., a woman presented with recto-cutaneous fistula eleven months after vaginal prolapse repair with tension free vaginal mesh. Magnetic resonance imaging and colonoscopy revealed a migration of the mesh and a recto- cutaneous fistula which was later repaired surgically. The biological reaction of synthetic prosthesis and the mechanism of mesh erosion is well documented, however there is little understanding regarding the cause and mechanism of mesh migration. Although the possibility of mesh migration after vaginal wall prolapse repair is comparatively low, serious consequences would result if left untreated. Further studies are advised to investigate the mechanism and complications of mesh migration. 1.Wright ED, Chiphangwi J, Hutt MS. Schistosomiasis of the female genital tract. A histopathological study of 176 cases from Malawi. Trans R Soc Trop Med Hyg 1982;76(6): Kameh D, Smith A, Brock MS, Ndubisi B, Masood S. Female genital schistosomiasis: case report and review of the literature. South Med J 2004;97(5): Norton P, Baker J, Sharp H, et al. Genito-urinary prolapse: Relationship with joint mobility. Neuro Urodyn. 1990;9: Kaupp HA, Matulewicz TJ & Lattimer GL. Graft infection or graft reaction? Arch Surg 1979;114: Surgical Repair of Vaginal Wall Prolapse using Mesh. National Institute for Health and Clinical Excellence Taoka R, Mizuno K, Matsuoka T et al. Case of rectal migration of mesh after TVM operation. Nihon Hinyokika Gakkai Zasshi 2011 Nov;102 (6): Surgical repair with mesh involves removing some of the stretched tissue and tightening of the underlying tissue. A mesh is then used to support the repair. There is a number of different biological and synthetic mesh materials available, vary in structure and strength. The ideal prosthesis should be inert and biocompatible, have a minimal initial inflammatory and cellular response followed by vascular and fibroblastic infiltration. The promotion of fibrous growth around the mesh without tissue infiltration is associated with the phenomenon of ‘encapsulation’ which decreases the efficacy and increases the risks of erosion [4]. National Institute of Clinical Excellence (NICE) guideline suggest that surgical repair of vaginal wall prolapse using mesh may be more effective than traditional surgical repair without mesh [5]. Both efficacy and safety vary with different type of surgical techniques and mesh, although long term data in efficacy are limited in quantity The use of biological graft and synthetic mesh was reviewed, to study their effectiveness and outcomes in the Cochrane review. The aim of using the mesh is to add additional support and reduce the risk of recurrence. Nine studies with a total of over 400 women reported the use of mesh in posterior vagina repair. Common complications mentioned were damage to surrounding organs, constipation/incontinence, dyspareunia and cervical/rectal erosion. According to NICE guideline, four studies of 276 women in total reported that damage to surrounding organs during surgery occurred in 0% to 4% using mesh. De novo urinary incontinence was not reported in any study. In one case series, de novo defaecation difficulties were reported in one woman and constipation in two women at 6- to 12- week follow up. In a second case series, de novo faecal incontinence was reported in 3% of women at a mean follow up of 17 months. Two case series reported de novo dyspareunia in 6% of women treated with combined synthetic mesh at a follow-up of 6 months. Two case series of 121 women reported mesh erosion rates of 14% for combined synthetic mesh at a mean follow-up ranging from 6 to 18 months. A literature search was performed using MEDINE and the COCHRANE library, one case report was identified relating to mesh migration [6]. A 76 years’ old Caucasian lady presented in the out patient clinic. She is a known Jehovah’s witnesses, who has had two normal vaginal deliveries with no complications in her late twenties. At the age of 51, she presented with a history of irregular and heavy vaginal bleeding. She had a total abdominal hysterectomy and bilateral salpingoopherectomy for menorrhagia which was uneventful. She is known to have hypertension, ischaemic heart disease and gastro-esophageal reflux. She has no other significant surgical history. Her BMI is within normal range. She is retired and non-smoker. Seventeen years later, she was referred by her GP with a history of discomfort and the feeling of a ‘lump’ in the vagina. No urinary or bowel symptoms were reported. She was assessed in the outpatient gynaecology clinic and examination revealed a moderate degree of vault prolapse and a rectocoele. No other physical findings were detected She was offered surgical treatment for her prolapse and consented for posterior vaginal repair and vault suspension using a tension free mesh.. The procedure was performed a couple of weeks after the diagnosis. The mesh used was a polypropylene and polyurethane monofilament mesh (Recto-swing®). The operation itself was uneventful with minimal blood loss and no immediate complications. She made a good recovery and her 6-week follow up was satisfactory with no reported urinary or bowel symptoms. Six years following the procedure, she presented to her GP with a 6 months’ history of recurrent rectal bleeding and discomfort. The bleeding was described as bright red in colour with no mucus noted. There were no associated abdominal pain, change in bowel habit or weight loss. She was later referred to the colorectal team for investigation. Her abdominal examination and per rectal examination was unremarkable. She had a flexible sigmoidoscopy, the findings of which were normal. She was reassured and discharged from the colorectal clinic. Eighteen months later, she came back to her GP again with similar but more frequent symptoms. She was urgently referred to the colorectal surgeons. Subsequent rectal examination revealed a mass on the anterior rectal wall along with fresh red bleeding. A proctoscope showed a foreign body protruding into the anterior rectal wall. Considering her previous history and after discussion with her gynaecologist consultant, the foreign body was found to be the synthetic mesh used in the posterior vaginal wall repair. The decided course of action was to retrieve the mesh in cooperation with the colorectal surgeon. LEARNING POINTS ØVaginal wall prolapse repair using mesh may be more efficacious than traditional surgical repair without mesh. ØBoth efficacy and safety varies with the type of mesh used and surgical technique. ØLong term complication data is limited in quantity and further systemic reviews need to be carried out. ØThese technically challenging procedures should only be undertaken by experiences gynaecologists, registered with clinical governing bodies or performed as research/auditable procedures. ØMesh erosion is a well recognised complication in the literature along with recurrence of prolapse, urinary and bowel complications but mesh migration and recto- vaginal fistula are rare and not fully understood. INTRODUCTIONINTRODUCTION DISCUSSIONDISCUSSION Pelvic floor disorders are complex and multifactorial. The incidence as mentioned above varies and is difficult to determined. In a retrospective cohort study the lifetime risk of undergoing at least one prolapse surgery is 11%. Risk factors include multi-parity, increase intra-abdominal pressure e.g. obesity, chronic obstructive pulmonary disease and chronic constipation [2]. Connective tissue disease e.g. Marfan disease have also been linked to genitourinary prolapse [3]. Current treatment options for anterior and/or posterior vaginal wall prolapse include pelvic floor muscle training, use of mechanical devices (ring or shelf pessaries) and surgery.