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

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

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

Intraoperative Complications Bleeding Injury to Bladder Injury to Urethra Injury to Nerves Injury to Bowel

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

Anatomy of Anterior Vagina 8

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

TVT with bladder perforation

Rinehart; calculi

Transobturator Approach Anatomy of obturator foramen

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

M. OBTURATOR EXT M. OBTURATOR INT

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

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

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

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

Needle entry & path

Transobturator Anatomy Anterior Vagina

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

Eroded OB tape

Eroded TVT; urethrovaginal Fistula

TVT SECUR in Urethra

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

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%

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

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). Hiltunen R, et al. Obstet Gynecol. 2007

Serious Delayed Complications with Mesh in RPS 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.

Mesh Erosion; vault suspension

Mesh in Rectum

G Fields

Mesh removal after vag hyst

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