Classification of mesh fiber exposure: reply

Abstract

Dear Editor,On behalf of the authors, I thank Dr Al-Badr for his interestin the document [1]: An International UrogynecologicalAssociation (IUGA) / International Continence Society(ICS) joint Terminology and Classification of complicationsrelated directly to the insertion of prostheses (meshes,implants, tapes) and grafts in female pelvic floor surgery.It is pleasing the report has been found to be useful.The main point made by Dr Al-Badr [ 2] appears to concernthe inclusion of fibre in category 1 of theclassification [1] rather than category 2. The issue rests on thedefinition of (vaginal) separation, which is currentlyapplicable, to exposures in categories 2 and 3 of theclassification but not to category 1 complications. Dr Al-Badrappears to argue that a separation of vaginal epithelium byone fibre is still a separation. The definition of separationused in the Terminology section of the Report [ 1]isthatofphysically disconnected. It may be hard to assert thatvaginal epithelium pierced by one or more than one fibre of aprosthesis is physically disconnected. The Report maintainsthat there needs to be clear physical disconnection (separa-tion) of vaginal epithelium with visualization of vaginalmesh to create an exposure (categories 2 and 3).Dr Al-Badr makes a further point [2] that the classifica-tion [1] does not distinguish between mesh fibre palpationunder the vaginal epithelium and mesh palpation and/orvisualization through the epithelium. The suggested argu-ment is that the management may well be different, whichmay perhaps, at times, be the case. It is agreed that meshfibres felt under the epithelium without being seen (or felt)in the vagina qualifies for category 1A (especially as it islikely to be asymptomatic and generally requiring notreatment). For the reasons outlined above in relation tothe definition of separation, mesh fibres seen or feltthrough the vaginal epithelium would still only qualify ascategory 1. The category would be 1A if there were nosymptoms or 1B is there were symptoms (possiblyrequiring treatment), with a common symptom beingdyspareunia to the partner. The classification does thendistinguish between the scenarios presented by Dr Al-Badron the basis of the likely presence or absence of symptomsand the possible associated need for treatment.