An Unusual Delayed Complication of Urogynecologic Surgical Mesh Placement: Perirectal Abscess 10 Years After Initial Placement Treated by Endoscopic Removal and Transrectal Drain Placement: ACG Case Reports Journal Award: Presidential Poster Award

Abstract

INTRODUCTION: More than 500,000 surgical procedures are done annually for management of symptomatic pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Surgical mesh has been used in these surgeries for more than 20 years. However, an increasing number of reports of adverse effects have been described, particularly with transvaginal route of mesh insertion, which has led to issuance of FDA guidelines regarding the use of mesh in urogynecological procedures. Here we describe an uncommon complication of perirectal fistula and abscess associated with surgical mesh that was successfully managed with endoscopic therapy. CASE DETAILS: A 63-year old diabetic woman with urinary incontinence underwent robotic-assisted laparoscopic sacrocolpopexy (Burch procedure) along with polypropylene mesh placement in 2008. She did well until rectal bleeding 7 years later. Sigmoidoscopy showed protrusion of the mesh from the anterior wall of the rectum. During anoscopy under anesthesia, a 2cm length of mesh was cut out. She did well for 18 months before experiencing worsening low back and groin pain. CT scan revealed a 3 x 3 x 8cm fluid collection anterior to the rectum. Percutaneous drainage was attempted but a suitable window could not be found for drain placement. Long term antibiotics were given for several months, but she was readmitted for fevers. CT showed that the abscess now contained air. The patient was then referred for EUS-guided abscess drainage. Flexible endoscopy revealed purulent drainage through a pinpoint low rectal fistula. A through the scope balloon dilator was used to enlarge the fistula to 12 mm. After entry into the cavity a large piece of coiled surgical mesh was seen. The proximal margin was released using an endoscopic scissors, and a 9cm length of mesh removed. Two 7Fr x 5 cm double pigtail stents were placed in the cavity. CT 3 weeks later showed near complete resolution of the abscess and spontaneous extrusion of the stents. DISCUSSION: The use of surgical plastic mesh is common for management of POP and SUI, although increasing reports of adverse effects are being seen. The occurrence of a perirectal abscess is uncommon. This is the first reported case of endoscopic management of an abscess and removal of retained mesh. With increasing use of flexible endoscopic transrectal abscess drainage (usually under EUS guidance), this approach should be considered earlier in the management of perirectal abscesses.2164_A Figure 1. Coronal CT shows a large perirectal abscess.2164_B Figure 2. A through-the-scope dilation balloon is introduced through the fistula; purulent drainage is seen.2164_C Figure 3. After entry into the abscess cavity, a coiled piece of polypropylene surgical mesh is encountered.