Images from Retropubic placementTransobturator placement

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Haylen et al.: Neurourol and Urodynamics 2011

The generic term of “erosion” (medically defined as the “state of being worn away, as by friction or pressure”), doesn’t necessarily suit the clinical scenarios encountered. Its use has been abandoned.

NYU 2011

Maher et al. Cochrane Library 2013 Maher et al. 5 th ICI, 2013, MUS POP Mesh  Mesh exposure 3%  Mesh perforation 0.5%

Surgeon Experience/Wisdom TVM Complications Patient Characteristics Mesh/Kit Properties Aggressive Marketing

65 yo female had an anterior repair with mesh kit 3 years ago She began having pain and bleeding with intercourse 6 months ago Her partner can feel a scratchy sensation during intercourse Vaginal Wall Mesh Exposure Diagnosis

 Placement too superficial  Vaginal atrophy  Mesh folding  Mesh bunching  Incision dehiscence POTENTIAL CAUSES OF MESH EXPOSURE, EXTRUSION

Vaginal Wall Mesh Exposure Surgical Options *  Office trimming  Minor excision  Minor excision + flap mobilization and vaginal wall closure  Partial mesh removal  Mesh preserving approach with allograft coverage * Shah HN and Badlani GH: Indian J Urol 2012 † Terlecki RT and Flynn BJ: AUA update series 2010 Simple Technique: Transvaginal Complex Technique  Major excision + flap mobilization and vaginal wall closure  Near total mesh removal  Total (complete) mesh removal  Laparoscopic approach Least Invasive Most Invasive

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65 yo female had an anterior repair with mesh kit 3 years ago. She began having pain and bleeding with intercourse 6 months ago Her partner can feel a scratchy sensation during intercourse Transvaginal near-total mesh excision Vaginal Wall Mesh Exposure Operative Management

Exposure 5x10mm exposed Prolift PS

Paravaginal Hydrodissection Dissection Breisky-Navratil Retractor

Anterior Strap Transection

Posterior Strap Transection Deep Dissection Bladder Mesh

Prolift PS™ Explant

Bladder Mesh Perforation POP Mesh Kit

Open ended catheter in right ureter Anterior mesh arm Locking eyelet and apical fixating arm Example of bladder mesh perforation of AMS™ anterior Elevate Kit

Bladder Urethra LUT Mesh Perforation Mid-Urethral Mesh Sling

 unrecognized LUT perforation at the time of mesh implantation  unrecognized LUT trocar tunneling in the detrusor muscle  deep overlapping mesh placement  mesh insertion at the location of a recognized and repaired LUT injury POTENTIAL CAUSES OF LUT MESH PERFORATION Bladder Urethra Shah K and Flynn BJ: Int Urogyncol J 2013  primarily due to excessive sling tension  undue delay in sling lysis

Urethra High index of suspicion in patients with Hematuria, bladder pain, urgency, calculus adherent to the bladder wall LUT Mesh Perforation Diagnosis Terlecki RT and Flynn BJ: AUA update series 2010 Do not delay sling lysis Avoid urethral dilation Bladder Bladder incomplete emptying/retention Incontinence

Urethral Mesh Perforation after MUS Options Shah K and Flynn BJ: Int Urogyencol J 2014 Options Observation?? Transurethral removal – endoscopic scissors – laser – Other Transvaginal excision

Bladder Mesh Perforation after MUS Endoscopic Approach, * Davis NF et al: J Urol 2012 Holmium Laser  Location of mesh perforation  urethral (n = 2)  bladder (n = 10)  Perforated mesh excised  Perforated mesh excised in 19 mins (range 10-25)  Mesh resolution in 8/12 (67%) in a single operation  No. of laser p rocedures  1 procedure (8)  2 procedures (4)  3 procedures (1)  Open procedure (1)  Recurrent SUI 2/12 (17%)

Bladder Mesh Perforation after MUS Robotic Laparoscopic Approach * Ropuert M et al: Eur Urol 2010 Lap Excision *  Location of injury  vaginal wall (n = 29)  urethra (n = 0)  bladder (n = 9)  Lap excision  Lap excision 110 mins (range )  Mesh resolution in 38/38 (100%) in a single operation  No. of Procedures 1 procedure (38/38) 1 procedure (38/38) Recurrent SUI Mesh exposure, 16/29 (55%) MUS perforation, 9/9 (100%)

Bladder Mesh Perforation after MUS Transvaginal/Combined Approach Shah K and Flynn BJ: Int Urogyencol J 2014  Location of mesh perforation Urethra (n = 14) Urethra (n = 14) bladder (n = 7) bladder (n = 7)  No major intraoperative complications  Mesh resolution in 20/21 (95%) in a single operation  Recurrent SUI urethra, 1/14 (7%) urethra, 1/14 (7%) bladder 0/10 (0%) bladder 0/10 (0%) MUS Complete Removal

56 yo female had MUS placed for SUI 18 months ago She noticed blood in the urine 3 months ago and frequently has dysuria Vaginal Wall Mesh Exposure Diagnosis

Vaginal Wall Mesh Exposure Operative Management 56 yo female had MUS placed for SUI 18 months ago She noticed blood in the urine 3 months ago and frequently has dysuria Transvaginal near-total mesh excision, urethral repair

Management of Mesh Complications Operative Technique and Outcome Simple (n = 27) Complex (n = 49) 15 (56%) 3 (5%) Re-excision of mesh rates Hadley and Flynn AUA 2011

MUS: 60% of total cases POP Mesh Kit: 31% of total cases MUS + POP Mesh Kit: 9% of total cases Flynn TVM (MUS + POP Kits) Explant Case Log Shah K and Flynn BJ: Int Urogyncol J 2013 Mesh Kit Total Midurethral Sling Kit POP Mesh Kit MUS + POP kit Total

MUS TOT Mini

ArmsBody AP length 3 cm

Painful Mesh MUS, POP kit H & P H & P Operative report Operative report Cystoscopy Cystoscopy Urodynamics Urodynamics Vaginal ultrasound Vaginal ultrasound EUA EUA Potential Causes Work-up Non-Operative Therapy NSAIDS/Narcotics NSAIDS/Narcotics Gabapentin Gabapentin Massage Massage Physical therapy Physical therapy Trigger point injection Trigger point injection

Vaginal Wall Complaints Mesh Exposure Mesh Pain Management of Transvaginal Mesh Complications Infection Causes Pain Mesh Infection

TVM associated pain Treatment algorithm NSAIDS/Narcotics NSAIDS/Narcotics Gabapentin Gabapentin Massage Massage Physical therapy Physical therapy Trigger point injection Trigger point injection Non-surgical therapy Surgical therapy  Partial/minor mesh excision  Near total mesh removal  Total (complete) mesh removal  Robotic/Laparoscopic approach Least Invasive Most Invasive

Images from Retropubic placementTransobturator placement Sling Revision/Removal for Mesh Erosion and Urinary Retention: Long-term Risk and Predictors. Funk et al. Occurs in about 1% of women undergoing MUS >

Transvaginal MUS Lysis Synthetic Sling Midline vaginal incision Sling ‘peeled’ off of urethra/incised Minimize lateral dissection Early: < 6 weeks Intermediate: 6 weeks – 6 months Late: > 6 months Midline and lateral dissection Mesh excision 1-3 cm Transvaginal urethrolysis More extensive dissection, excision Terlecki RT and Flynn BJ: AUA update series 2010

NYU 2011

TVT REINFORCES PUBOURETHRAL LIGAMENTS AND CREATES SUBURETHRAL HAMMOCK Iglesia TVT Gold Standard MUS is the Gold Standard for SUI TVM kit popular for all types of POP and as a primary procedure >1,000 complications reported in from 9 manufacturers TVM Kit 2010 Ulmsten surgicalmesh.html TVM Erosion rate 16% after POP surgery, no difference in cure rates FDA PHN Iglesia Study Chapple 2003

2011 1/2012 7/2012 FDA Update FDA orders TVM manufacturers to go back and study their products Ethicon, Bard stop manufacturing POP kits and some mini-slings 522 Studies Ordered 2013 SUI and POP surgeries decrease, trends toward native tissue and biologicals Industry Reaction Mesh Hangover 5 million dollars awarded to plaintiff in California v. CR Bard, hospital and MD

 More women requesting native tissue repairs  More time spent obtaining informed consent  More time spent discussing TV adds and FDA PHN  Rise in urethral bulking and treatments for OAB  Lap/Robotic approaches with mesh gaining popularity

“It is the AUA’s opinion that any restriction of the use of synthetic polypropylene mesh suburethral slings would be a disservice to women who choose surgical correction of SUI.” Midurethral Sling Task Force This position statement was drafted by members Charles Nager, Paul Tulikangas, and Dennis Miller from AUGS and Eric Rovner and Howard Goldman from SUFU. Approved by the AUGS Board of Directors and the SUFU Board of Directors January 3, /3/2014