Mesh Complications Research Articles

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy

To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy. Single-center retrospective cohort study. Tertiary referral center. Women with symptomatic pelvic organ prolapse who elected for MISC. Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse. Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p=.31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p=.07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p=.57), or composite failure (9.0% vs 3.7% vs 4.8%; p=.07). TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

PJY02 - Simultaneous hernia repair in robotic-assisted radical prostatectomy is safe with low rates of mesh complications

PJY02 - Simultaneous hernia repair in robotic-assisted radical prostatectomy is safe with low rates of mesh complications

Holey sheet, not another mesh complication! A pictorial review of tertiary centre experience in MRI for mesh complications, alongside surgical correlation

Category: Gynaecological radiology

Study of Operative Outcomes of Hernioplasty Using Mosquito Net Mesh at a Tertiary Hospital.

BackgroundSynthetic mesh is the most efficient way to repair groin hernias. However, many patients in low and middle-income countries cannot afford the above-mentioned mesh. This study's goal was to describe the mosquito net mesh's (MNM) safety, viability, complications, and recurrence rate in hernioplasty done in rural populations.Material and methodsThis study was a single-centre, prospective, descriptive study, conducted in patients >18 years of age, of either gender, with unilateral or bilateral primary inguinal hernias (reducible/irreducible/bilateral hernia), admitted for elective or emergency open inguinal hernia mesh repair. The surgery was performed using reasonably priced (affordable to people of low socioeconomic status) polyethylene mosquito net mesh, which was cut into 8x16 cm rectangles and wrapped in two sealed plastic bags. They were sterilised using the ethylene oxide sterilisation (EtO) method. The type of hernia (unilateral or bilateral), post-operative pain, and complications were noted.ResultsAmong 400 study participants, the incidence of inguinal hernia was highest in the 60-79 year age group (51.5%). Direct inguinal hernia (67.5 %) was higher compared to indirect inguinal hernia (32.5 %). While a majority of the participants had a hernia on the right side (50%), 164 patients (41%) had a hernia on the left side, and 36 patients (9%) had a bilateral inguinal hernia. The average operative time for unilateral inguinal hernia was 73.96 minutes and for bilateral inguinal hernia was 106.66 minutes. Out of 400 patients, 355 patients (88.75%) had no complications. Among the postoperative patients, 14 patients (3.5%) experienced surgical site infection; 9 patients (2.25%) experienced headache; 5 patients (1.25%) experienced hematoma; 12 patients (3%) experienced urinary retention; and 5 patients (1.25%) experienced testicular pain. The average hospital stay of patients was 4.25 days. Patients returned to their daily activities and employment in an average of 7.29 days. The market cost of a single standard polypropylene mesh was Rs.1,660/-. For making a single mosquito net mesh of the same size, we had an expenditure of Rs. 11.83/- including the cost of sterilization. In this study, 382 patients (95.5%) gave us good feedback, 11 patients (2.75) gave satisfactory feedback, and 7 patients (1.75%) gave excellent feedback.ConclusionIn environments with limited resources, using mosquito net mesh for hernioplasty is reasonable, acceptable, doable, and economical.

PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse

Introduction and hypothesisOur aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse.MethodsA total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures.ResultsAt 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups.ConclusionsAt the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.

A Narrative Review on Polypropylene Mesh Complications in Inguinal Hernia Repair - is Titanized Mesh an Option?

A Narrative Review on Polypropylene Mesh Complications in Inguinal Hernia Repair - is Titanized Mesh an Option?

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Quality of Pre-operative Assessment for Mid Urethral Slings in Women Who Present With Mesh Complications

ObjectiveTo study quality of pre- and post-operative evaluation in women undergoing mid-urethral synthetic sling surgery who subsequently have complications. Materials and methodsStudy inclusion was chart availability for preoperative clinical history, examination, urodynamics and/or post-operative visit in women with mesh complications 2014-2021 in a tertiary practice. The primary outcome was compliance with quality indicators and guidelines for preoperative and post-operative clinical evaluation and urodynamics. Results122 women had preoperative, 102 urodynamic reports and 108 post-operative charts available for review. Only clinical history and examination showed moderate compliance (71% nature, 57% severity, 87% exam) with quality indicators, all other quality indicators were low. including documentation of counselling of mesh risks (11%) and risks of incontinence surgery (17%) . Compliance with guidelines (optimal care) was also low (bladder diary 61%, all others ≤41%). Post-operative evaluation did not comprehensively screen for complication e.g., flow rate/post-void residual performed in 9%. A significant proportion had an early adverse symptom (55%) or intervention e.g. trimming of exposure (40%) ConclusionCompliance with quality indicators and guidelines was generally low for pre-operative evaluation and urodynamic testing. There was inadequate content and length of post-operative evaluation despite a significant proportion presenting with adverse symptoms at first postoperative follow-up. Future research could target these areas for development of tools to improve compliance and education of health providers.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in treatment of head titanium mesh exposure with soft tissue infection

To explore the effectiveness of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction in the treatment of head titanium mesh exposure complicated with soft tissue infection. Between January 2015 and December 2021, 13 patients with head titanium mesh exposure complicated with soft tissue infection were admitted. There were 9 males and 4 females with a mean age of 42.9 years (range, 23-64 years). The duration of titanium mesh exposure was 22-609 days (median, 102 days). The wound site located at the frontal part in 3 cases, the parietal part in 1 case, the occipital part in 2 cases, the frontal-parietal part in 1 case, the temporal-parietal part in 4 cases, and the frontotemporal part in 2 cases. The titanium mesh had been taken out in 5 patients before admission, leaving skull defect and shape collapse, with signs of infection. The bacterial culture was positive in 7 cases and negative in 6 cases. The imaging examination revealed that the size of the skull defect ranged from 6 cm×5 cm to 21 cm×17 cm and the scalp defect ranged from 1 cm×1 cm to 15 cm×10 cm. The soft tissue infection did not reach dura in 5 cases, reached dura in 6 cases, and reached frontal sinus in 2 cases. The two-stage surgical protocol was used in all patients. In the first-stage operation, the latissimus dorsi myocutaneous flap was designed to repair the skull and scalp defects after removing the titanium mesh and thorough debridement. The size of muscle flap ranged from 13.5 cm×4.0 cm to 21.0 cm×17.0 cm, and the skin flap ranged from 7.0 cm×4.0 cm to 15.0 cm×10.0 cm. After the flap survived and stabilized, the second-stage operation was performed. The titanium mesh was implanted to reconstruct the skull contour. The size of titanium mesh ranged from 7.0 cm×6.0 cm to 21.5 cm×17.5 cm. The interval between the first- and second-stage operations was 3.7-17.8 months, with an average of 11.4 months. The survival of the skin flap, the appearance of the head, and the presence of re-exposed titanium mesh and infection were observed after operation. At the first-stage operation, venous embolism occurred in 1 case, and no obvious abnormality was observed after treatment. All the flaps survived and the incisions healed by first intention. Besides, the incisions of the second-stage operation healed by first intention. All patients were followed up 1-96 months (median, 14 months). During follow-up, no exposure to titanium mesh, infection, or other complications occurred. The appearance satisfaction rate of the patients was 92.31% (11/13). There was no significant difference in the skull contour between the affected side and the healthy side in all patients. For the head titanium mesh exposure with soft tissue infection, the application of two-stage operation on free latissimus dorsi myocutaneous flap transplantation and skull contour reconstruction can reduce the risks of implant exposure and infection again by increasing the thickness of the scalp and blood supply, filling the wound cavity, and obtain good effectiveness.

The clinical application of transperineal ultrasound in urogynaecology

Key content Transperineal ultrasound allows reproducible imaging of pelvic floor conditions that aids in the thorough assessment required to diagnose and treat urogynaecological conditions. Views that can be obtained include two‐dimensional (2D) sagittal views of the bladder neck, urethra and pelvic floor; 2D coronal views of the anal canal; and three‐dimensional (3D) or four‐dimensional (4D) views of the genital hiatus and anal canal. This allows assessment of the post‐void residual volumes, detrusor wall thickness and dynamic assessment of the urethral morphology. Ultrasonographic assessment enables accurate information about maternal birth trauma to be ascertained, including levator ani muscle avulsion and obstetric anal sphincter injury. Transperineal ultrasound can be used to identify and assess previously implanted vaginal mesh and midurethral slings. Learning objectives To understand the role of ultrasound in clinical urogynaecology practice, including the assessment of slings and meshes. To know the ultrasound probes, techniques and views used to image the pelvic floor and anal sphincters by transperineal ultrasound. To describe assessment of the lower urinary tract, pelvic organ prolapse and obstetric anal sphincter injury using ultrasound. Ethical issues Thorough assessment of the pelvic floor is mandatory against the background of technological advances in the investigation of pelvic floor dysfunction. As a common and major complication of childbirth, maternal birth trauma must be assessed fully to support primary and secondary prevention. Thorough assessment must underlie the use of mesh implants, and dealing with sling and mesh complications is enhanced by imaging.

Prolapse and mesh reoperations following sacrocolpopexy: comparing supracervical hysterectomy, total hysterectomy, and no hysterectomy.

Sacrocolpopexy is effective for apical prolapse repair and is often performed with hysterectomy. It is unknown whether supracervical or total hysterectomy at time of sacrocolpopexy influences prolapse recurrence and mesh complications. The primary objective of this study is to compare reoperations for recurrent prolapse after sacrocolpopexy with either supracervical hysterectomy or total hysterectomy, or without concomitant hysterectomy. We also sought to compare these three groups for the incidence of mesh complications and describe cervical interventions following supracervical hysterectomy. A retrospective cohort study of sacrocolpopexy was performed using the MarketScan® Research Database. Women > 18 years who underwent sacrocolpopexy between 2010 to 2014 were identified. Utilizing diagnostic and procedural codes, reoperations for prolapse and mesh complications were identified. Women with < 2 years of follow-up were excluded. From 2010 to 2014, 3463 women underwent sacrocolpopexy with at least 2 years of follow-up, 910 (26.3%) with supracervical hysterectomy, 1243 (35.9%) with total hysterectomy, and 1310 (37.8%) without hysterectomy. Reoperations for prolapse were similar after supracervical hysterectomy (1.5%), after total hysterectomy (1.1%, p = 0.40), and without hysterectomy (1.5%, p = 0.98). Mesh complications after sacrocolpopexy were similar after supracervical hysterectomy (1.8%), after total hysterectomy (1.5%, p = 0.68), and without hysterectomy (2.8%, p = 0.11). Following supracervical hysterectomy, 0.9% underwent cervical procedures. When comparing supracervical and total hysterectomy at time of sacrocolpopexy, there were no significant differences in reoperations for recurrent prolapse, reoperations for mesh complications, or mesh complication diagnoses. This study shows that surgeons can be reassured on performing hysterectomy with sacrocolpopexy.

Mesh complications after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy.

Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates. This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records. Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups. Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.

Mesh deformation: A mechanism underlying polypropylene prolapse mesh complications in vivo

Polypropylene meshes used in pelvic organ prolapse (POP) repair are hampered by complications. Most POP meshes are highly unstable after tensioning ex vivo, as evidenced by marked deformations (pore collapse and wrinkling) that result in altered structural properties and material burden. By intentionally introducing collapsed pores and wrinkles into a mesh that normally has open pores and remains relatively flat after implantation, we reproduce mesh complications in vivo. To do this, meshes were implanted onto the vagina of rhesus macaques in nondeformed (flat) vs deformed (pore collapse +/− wrinkles) configurations and placed on tension. Twelve weeks later, animals with deformed meshes had two complications, (1) mesh exposure through the vaginal epithelium, and (2) myofibroblast proliferation with fibrosis – a mechanism of pain. The overarching response to deformed mesh was vaginal thinning associated with accelerated apoptosis, reduced collagen content, increased proteolysis, deterioration of mechanical integrity, and loss of contractile function consistent with stress shielding – a precursor to mesh exposure. Regional differences were observed, however, with some areas demonstrating myofibroblast proliferation and matrix deposition. Variable mechanical cues imposed by deformed meshes likely induce these two disparate responses. Utilizing meshes associated with uniform stresses on the vagina by remaining flat with open pores after tensioning is critical to improving outcomes. Statement of significancePain and exposure are the two most reported complications associated with the use of polypropylene mesh in urogynecologic procedures. Most meshes have unstable geometries as evidenced by pore collapse and wrinkling after tensioning ex vivo, recapitulating what is observed in meshes excised from women with complications in vivo. We demonstrate that collapsed pores and wrinkling result in two distinct responses (1) mesh exposure associated with tissue degradation and atrophy and (2) myofibroblast proliferation and matrix deposition consistent with fibrosis, a tissue response associated with pain. In conclusion, mesh deformation leads to areas of tissue degradation and myofibroblast proliferation, the likely mechanisms of mesh exposure and pain, respectively. These data corroborate that mesh implantation in a flat configuration with open pores is a critical factor for reducing complications in mesh-augmented surgeries.

Operative Time for Minimally Invasive Sacrocolpopexy: Comparison of Conventional Laparoscopy versus Robotic Platform

To evaluate the operative time for minimally invasive sacrocolpopexy using conventional laparoscopy vs robotic assistance. In addition, we sought to compare intraoperative complications, mesh complications, anatomic prolapse recurrence, and retreatment. Retrospective cohort study. Academic hospital. All 142 women who underwent minimally invasive sacrocolpopexy between January 1, 2019, and December 31, 2019. We compared operative time between laparoscopic and robotic-assisted sacrocolpopexies. A total of 142 women were included. Mean age was 61.8 ± 9.6 years and mean body mass index 27.1 ± 4.4 kg/m2. A total of 86 (60.6%) sacrocolpopexies were performed laparoscopically and 56 (39.4%) with robotic assistance. There were no significant differences in baseline demographic variables. A higher proportion of concomitant hysterectomies were performed with robotic assistance as compared with laparoscopic cases (n=42, 73.7% robotic vs n=43, 50.6% laparoscopic; p <.01). Mean operative times were significantly different between robotic and laparoscopic groups (176.3 ± 45.5 minutes and 195.0 ± 45.4 minutes, p = .02). On linear regression, the variables predicting significant change in operative time were robotic assistance, concomitant hysterectomy, age, body mass index, and no resident involvement. There were no differences in intraoperative bladder or bowel injury, anatomic recurrence beyond the hymen, retreatment, or mesh complications (all p >.05). Contrary to previous research, the use of robotic assistance does not appear to increase operative time for patients undergoing minimally invasive sacrocolpopexy in a large academic practice.

Ten-year surgical complications and mesh erosion of transvaginal Elevate™ mesh for management of pelvic organ prolapse

This study aims to review the surgical complications and mesh erosion with a cohort of patients who underwent Elevate™ mesh repair. This was a single-centre, retrospective study of women undergoing Elevate™ mesh reconstruction between 2006 and 2016. Women who presented with symptomatic prolapse of stage II or above were enrolled. The study outcomes were intra-operative and peri-operative complications (including mesh complications) at six weeks, one year and five years reporting with a standardised communicable method—the International Urogynecological Association (IUGA)/International Continence Society (ICS) scale and the Clavien and Dindo Classification. A total number of 350 women had Elevate™ mesh insertion. The mesh exposure rate was 1.1% and the surgical complication rate in our series was low and self-limiting (2% were Dindo grade 3). With the low morbidity and mesh-related complications, Elevate™ mesh should be at least kept as an alternative treatment of pelvic organ prolapse. Impact statement What is already known on this subject? Transvaginal mesh repair surgery was popular to treat advanced pelvic organ prolapse 10 years ago. However, after announcement of the Food and Drug Administration (FDA) public notification regarding mesh-related complications, particularly mesh exposure, use of transvaginal mesh and its safety have been scrutinised. Despite the increasing challenging and difficult medico-legal climate, several studies on second generation mesh kits, such as Elevate™ have shown favourable outcomes with low complication rates including our group. What do the results of this study add? In this paper, the surgical complications and mesh erosion of Transvaginal mesh was reported in a quantified communicable method—the International Urogynecological Association (IUGA)/International Continence Society (ICS) scale and the Clavien and Dindo Classification. This is significant because it is the largest case studies from a single centre with 350 patients. What are the implications of these findings for clinical practice and/or further research? This study well demonstrated using a standardised way to classify mesh exposure and peri-operative complications which is lacking in the past, while majority studies only focus to discuss on surgical outcome instead of complications. This may make a spark for future research analysis.

Use of Magnetic Resonance Imaging in women with suspected complications following insertion of implants for pelvic organ prolapse and stress urinary incontinence surgery

ObjectiveTo evaluate the role of Magnetic Resonance Imaging (MRI) in women presenting with suspected implant complications following surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Study designRetrospective single-centre cohort study in a designated tertiary referral centre. All women with vaginally and/or abdominally placed implants for POP or SUI who were referred with suspected mesh complications, and investigated with an MRI scan, between January 2018-October 2020 were included in the study. Results97 women were identified over this time-period with a total of 123 implants, a median age of 55 years (Range: 34–79) and an average insertion to presentation time of 84 months (Range: 2–300). 78% (74) had one implant in situ, with the remainder having at least 2 in situ. Transobturator tapes (TVT-O/TOT) were the most common implants [35% (43)]. Chronic Pelvic or abdominal pain was the most common clinical symptom [73.2% (71/112 primary complaints)] with provoked tenderness on examination being the most common clinical finding [27.8% (32/115 clinical findings)].MRI was more likely to detect abdominally placed implants [100% (all 30)] and Retropubic Tapes [89% (16/18)] when compared to Transvaginal POP implants [87.5% (28/32)] and TVT-O/TOT [67% (29/43)]. MRI identified both cases of Sacrocolpopexy mesh rupture as well as all 11 cases of infection (100%). In 91% (10/11) of these cases, MRI revealed the infection to be more widespread than clinical findings initially suspected. Cohen’s Kappa demonstrated excellent correlation between MRI and surgical findings in cases with implant related infection, rupture and normal findings (κ = 1; z = 4.58; p = 0.00000459). Conclusion(s)MRI can be a useful tool in assessment and management of patients with complications from implants. MRI can detect infection that may be more extensive that is initially clinically apparent in the outpatient setting. Abdominal implants appear to be easier to detect than transvaginal meshes and trans obturator tapes.

Are late hernia mesh complications linked to Staphylococci biofilms?

PurposeThe purpose of this study was to investigate the link between bacterial biofilms and negative outcomes of hernia repair surgery. As biofilms are known to play a role in mesh-related infections, we investigated the presence of biofilms on hernia meshes, which had to be explanted due to mesh failure without showing signs of bacterial infection.MethodsIn this retrospective observational study, 20 paraffin-embedded tissue sections from explanted groin hernia meshes were analysed. Meshes have been removed due to chronic pain, hernia recurrence or mesh shrinkage. The presence and bacterial composition of biofilms were determined. First, specimens were stained with fluorescence in situ hybridisation (FISH) probes, specific for Staphylococcus aureus and coagulase-negative staphylococci, and visualised by confocal laser scanning microscopy. Second, DNA was extracted from tissue and identified by S. aureus and S. epidermidis specific PCR.ResultsConfocal microscopy showed evidence of bacterial biofilms on meshes in 15/20 (75.0%) samples, of which 3 were positive for S. aureus, 3 for coagulase-negative staphylococci and 9 for both species. PCR analysis identified biofilms in 17/20 (85.0%) samples, of which 4 were positive for S. aureus, 4 for S. epidermidis and 9 for both species. Combined results from FISH/microscopy and PCR identified staphylococci biofilms in 19/20 (95.0%) mesh samples. Only 1 (5.0%) mesh sample was negative for bacterial biofilm by both techniques.ConclusionResults suggest that staphylococci biofilms may be associated with hernia repair failure. A silent, undetected biofilm infection could contribute to mesh complications, chronic pain and exacerbation of disease.

The Cumberlege Report and the development of the UK mesh centre network

Very few clinical debates have been as emotionally charged as the transvaginal mesh debate. The public furore over its use led to an independent enquiry, the IMMDS Review (Independent Medicines and Medical Devices Safety Review) better known as the Cumberlege Review after Baroness Cumberlege who led it. The report of the two year long enquiry was published in July 2020 and recommendations to avoid similar situations arising in future were made. One of the recommendations was the establishment of Mesh Centres which could provide standardised care to women with mesh complications irres-pective of where they presented in the UK. Lessons need to be learned from the mesh saga, and though innovation cannot be stifled, safeguards to protect patients must be put in place when any new procedure or intervention is introduced into clinical practice.

Characterization of vaginal immune response to a polypropylene mesh: Diabetic vs. normoglycemic conditions

ObjectiveUrogynecology meshes, typically manufactured from polypropylene, are widely used in the surgical treatment of stress urinary incontinence and pelvic organ prolapse. However, mesh-associated complications such as mesh exposure can develop in women undergoing mesh implantation, for which diabetes is an independent risk factor. We aimed to define the impact of diabetes on the vaginal immune response to mesh by comparing diabetic vs. normoglycemic conditions longitudinally in a rat sacrocolpopexy model.Methods: Diabetes (blood glucose ≥ 300 mg/dL) was induced in middle-aged female Wistar rats with streptozotocin (STZ). A polypropylene mesh was implanted on the vagina via modified sacrocolpopexy following bilateral ovariectomy and supracervical hysterectomy for 3-, 7-, and 42-days. Sham-operated controls underwent the same procedures without mesh. Mesh-associated inflammation, immune cell populations and cytokine/chemokine profiles were examined in the excised vaginal tissues.Results: Diabetes was reliably induced starting on the 3rd day following STZ injection. Under both normoglycemic and diabetic conditions, mesh caused a prolonged inflammatory response in the vagina with increased proinflammatory chemokines MCP-1 and MIP-1α as compared to Sham. Major differences between the two conditions were found at the later stage (42 days post-surgery), including an increased inflammation with larger foreign body granuloma and more giant cells at the mesh-tissue interface, increased fraction of macrophages in the immune cell population, and higher proinflammatory chemokine IP-10 in the diabetic group.Conclusion: Polypropylene mesh implanted on the vagina induces prolonged inflammation at the mesh-tissue interface. Diabetes increases the mesh-associated inflammation in the long term, which is related to a dysregulated macrophage response. Statement of significanceThis study investigated the mechanism underlying the increased risk in women with diabetes for developing mesh complications such as mesh exposure. The significance includes: (1) it is the first study investigating vaginal host response to a prosthesis under the influence of diabetes; (2) the longitudinal study design elucidated the dynamic changes of vaginal immune response to mesh from very early to late stages; (3) our findings may inform future mechanistic studies and studies investigating preventive/therapeutic strategies to improve the outcomes of women with diabetes receiving vaginal implants.