Mesh Extrusion Research Articles

Single incision sling (Ajust™) for the treatment of female stress urinary incontinence: 2-year follow-up

ObjectiveThe primary outcome of this study was to evaluate the subjective and objective outcomes of an adjustable Single Incision Sling (Ajust™ C.R. Bard Inc., New Providence, NJ, USA) for the treatment of SUI, with a 2-year follow-up.The secondary outcome was to evaluate the safety of this procedure and the impact of this mini-sling on the filling and voiding phases of the bladder. Study designIn our prospective multicenter study we included 95 females with a clinical symptomatic and urodynamic diagnosis of primary SUI, and unsuccessful previous conservative treatment.Cure rate was evaluated objectively, using a standardized cough stress test and subjectively using the patient global impression of improvement. The King's Health questionnaire was used to evaluate quality of life (QoL). Urgency was evaluated using the patient perception of intensity of urgency scale.Complications were assessed intra-, peri- and post-operatively. All patients underwent urodynamic studies pre-operatively and at 6 months.The McNemar chi-square test was used to compare categorical variables, the paired t-test for continuous parametric variables, and the Fisher exact test for continuous non-parametric variables.A logistic regression model and odds ratios (with 95 percent confidence intervals) were used to assess the independent prognostic value of four variables for the outcome (age, parity, body mass index and menopausal status). Results92 Patients completed the 2-year follow-up. The objective cure rate was 83.7% and the subjective cure rate was 81.5%.De novo urgency was present in 9 patients (9.8%) and was associated with de novo urge incontinence in 6 patients (6.5%). Only 1 patient with de novo urge incontinence showed de novo detrusor overactivity.Regarding QoL, the King's Health Questionnaire indicated a statistically significant improvement in all domains except sleep.We observed no intraoperative complications. Post-operatively 1 patient referred pain in the right leg, 3 patients had mesh extrusions, 1 patient had recurrent urinary tract infections.Post-operative urodynamics showed a statistically significant increase of detrusor pressure at maximum flow and a reduction of maximum flow rate. No patients were obstructed according to the Blaivas and Groutz nomogram.

Anterior-Apical Single-Incision Mesh Surgery (SIMS): Surgical and Functional Outcomes at 1 Year

Study ObjectivesTo study the surgical and functional outcomes of single-incision mesh surgery for treatment of advanced pelvic organ prolapse (POP). DesignCase series (Canadian Task Force classification II-3). SettingUniversity hospital. PatientsSixty-five patients who underwent surgery to treat symptomatic POP greater than stage II according to the Pelvic Organ Prolapse Quantification System (POP-Q). InterventionAll patients underwent anterior-apical single-incision mesh surgery using the Elevate Anterior and Apical Prolapse Repair System. Measurements and Main ResultsThe primary objectives were anatomical correction of anterior and apical prolapse of POP stage I or greater and absence of voiding dysfunction reported via multi-channel urodynamic study at 6 months after surgery. Subjective outcome was measured via patient feedback using questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6). The secondary outcome was quality of life using the following: Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), POPDI-6, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Two-dimensional introital ultrasonography was performed in the first and third months after surgery and at 1-year follow-up. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. For all comparisons, a value of p < .05 was considered statistically significant. All statistical methods were performed using commercially available software (SPSS version 17). Postoperative data were available for 64 patients. The objective outcome was 96.9%, and the subjective outcome was 93.8%. All patients demonstrated significant improvement in anatomical outcomes after prolapse surgery (p < .05), and none experienced recurrence requiring further surgery. There was concomitant significant improvement in POPDI-6, UDI-6, IIQ-7, and PISQ-12 scores after surgery. A subanalysis of POP quantification measurements immediately after surgery and at 1-year postoperative follow-up demonstrated deepening of the C point and total vaginal length. Ultrasound evaluation demonstrated a significant increase in the length and thickness of mesh at 1-year follow-up. There has been no documented mesh extrusion to date. However, the number of patients with stress urinary incontinence has increased. Four patients received treatment, whereas in the remaining patients the condition was not severe enough to require surgical intervention. ConclusionsSingle-incision mesh surgery for treatment of advanced POP results in improvement in anatomical and quality-of-life outcomes. No mesh exposure was recorded in the first year after surgery; however, new onset of stress urinary incontinence may occur. Ultrasound evaluation demonstrated an increase in mesh length and thickness over time, with concurrent calculated lengthening of the C point and total vaginal length.

The incidence of mesh extrusion after vaginal incontinence and pelvic floor prolapse surgery

Purpose: The advantages of using synthetic mesh in vaginal reconstructive surgery are significant. However, the concern about extrusion has led many to question its use. We wished to learn the extrusion rates and time to extrusion in patients undergoing vaginal stress incontinence and prolapse surgeries using polypropylene mesh. Materials and methods: Five hundred and seventy six women underwent vaginal reconstructive surgery with synthetic mesh between August 2000 and October 2009 for the treatment of stress urinary incontinence, with or without pelvic organ prolapse repair. 367 patients had at least one year follow-up. Procedures were: pubo-vaginal sling (PVS), PVS and anterior repair, PVS with anterior and/or posterior repairs, and PVS with hysterectomy and anterior and posterior repairs. Time to mesh extrusion was estimated using a survival function curve. Results: Forty-two (11.4%) patients sustained a mesh extrusion. The rate of mesh extrusion was (6.3%) in the PVS group, (14.7%) in the PVS and anterior repair group, (11.1%) in the PVS with anterior and posterior repairs group and (5%) in the PVS with hysterectomy and anterior and posterior repair. Percent extrusion free at one to four years post-op was (91%) and (85%). Conclusion: Our study provides a large series of prolapse cases performed by a single surgeon with follow-up that extends at least one year, with the longest follow-up at eight years. The incidence of long term mesh extrusion needs to be considered with respect to the support advantages of synthetic mesh in planning vaginal reconstructive surgery.

Vaginal Trachelectomy Following Laparoscopic Supracervical Hysterectomy and Sacrocervicopexy

Current evidence supports cervical preservation at the time of abdominal prolapse repair using synthetic mesh to minimize vaginal mesh extrusion. This report aims to describe management of benign cervical disease following laparoscopic sacrocervicopexy including successful trachelectomy performed vaginally. A 70-year-old sexually active woman presented with symptomatic pelvic organ prolapse and stress urinary incontinence. Her Papanicolaou smears over several years were unremarkable, and she had a benign endocervical polyp removed in the office 3 months before surgery. She underwent an uncomplicated robotic-assisted laparoscopic supracervical hysterectomy and sacrocervicopexy. She presented 8 months after surgery with persistent vaginal spotting after intercourse and was found to have a recurrent endocervical polyp. Ultimately, she underwent uncomplicated trachelectomy performed vaginally with resolution of her symptoms. Retention of the cervix at the time of mesh-augmented abdominal prolapse repairs introduces a unique set of evaluation and management considerations for benign cervical disease. Trachelectomy performed vaginally was successful and uncomplicated in this case.

Early complications of the transobturator tape and mini sling procedure

Mesh extrusion was detected in 6 (4.6%) and 18 ( 10.9 %) cases of the TOT and mini sling group, respectively. There was a statistically significant difference about mesh extrusion (p: 0.036). Ten patients (6.1%) and eight cases (6.15%) had de novo urge incontinence responsed to medical theraphy in the post-operative follow-up in the mini sling and TOT groups, respectively. Two patients (1.2%), who underwent the mini sling procedure, required sling section due to prolonged bladder outlet obstruction. Significant infection complication due to operation was not detected. Three and one cases complained of thigh pain in the TOT and mini sling group, respectively. Conclusions: Mini sling procedure, when compared with suburethral tape,had similar complication rates except relatively high mesh erosion rates with comparable success rates. All cases should be carefully followed for late complications.

Hyperbaric Oxygen Therapy to Promote Vaginal Wall Healing after Salvage Surgery for Mesh-related Complication

Patients with multiple failed vaginal surgeries utilizing synthetic mesh present a therapeutic challenge. We present a case of a 75-year-old woman with severe stress urinary incontinence and mesh extrusion after two failed synthetic sling surgeries. Surgical reconstruction consisted of mesh excision, urethral reconstruction with vaginal tubularization, autologous rectus fascia sling placement. The patient developed a vaginal hematoma and wound dehiscence post-operatively, which was treated with surgical debridement and hyperbaric oxygen (HBO). The patient’s wound healed well, and she regained full continence, which was sustained at 10 months postoperatively. HBO therapy promotes wound healing after complex transvaginal reconstructive surgery.

Robotic Sacrocolpopexy for the Management of Pelvic Organ Prolapse

Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. The aim of our study was to review subjective and objective outcomes including complications after robotic assisted laparoscopic sacrocolpopexy for the repair of symptomatic pelvic organ prolapse. Single-site retrospective cohort study of women undergoing robotic assisted laparoscopic sacrocolpopexy with and without concomitant robotic assisted supracervical hysterectomy was performed. Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 questionnaires were used preoperatively and postoperatively to evaluate patient subjective data, respectively. We established a strict improvement of greater than 70% on questionnaire's total score to determine clinical improvement. Complications were assessed at 6 months and 127 women were included in our review. Mesh extrusion occurred in 3 (2.4%) patients. Other complications reported were bowel injury (2.4%), readmission rate (2.4%), wound infection (1.6%), and postoperative hernia at port site (1.6%). Objective and subjective outcomes were assessed at 1 year in 92 women. Although there was no recurrent apical prolapse at 1 year, anterior prolapse was present in 7 patients. Clinical improvement was present in 72% by Pelvic Floor Impact Questionnaire-7 and in 68% by Pelvic Floor Distress Inventory-20. Predictors of poor clinical outcomes were lysis of adhesions (OR, 5.83; 95% confidence interval [CI], 1.2-27.4; P = 0.026), urethrolysis (OR, 11.91; 95% CI, 1.2-117.9; P = 0.034), current smoking (OR, 7.9; 95% CI, 1.1-58.7; P = 0.042), and older age (OR, 1.1; 95% CI, 1.0-1.18; P = 0.044). Robotic assisted laparoscopic sacrocolpopexy represents a safe and effective surgical therapy to manage symptomatic apical pelvic organ prolapse. Serious complication rates are low but not rare when assessing short-term outcomes.

Anterior vaginal compartment surgery

To review the safety and efficacy of anterior vaginal compartment pelvic organ prolapse surgery. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and the Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. A grade C recommendation usually depends on level studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. A grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Absorbable mesh augmentation of anterior compartment native tissue repair improves the anatomical outcome compared with native tissue repair alone with no increased complication rate in meta-analysis of 2 RCTS (grade B). Biological grafts in meta-analysis have improved anatomical outcomes with no change in subjective outcomes compared with native tissue repairs (grade B). There is conflicting level 1 evidence to support porcine dermis and a single RCT to support small intestine submucosa as graft agents in anterior compartment prolapse surgery (grade B). Consistent level 1 data support a superior anatomical outcome for polypropylene mesh compared with a biological graft in the anterior compartment. Mesh exposure rate was significantly higher in the polypropylene mesh group (grade A). Consistent level 1 evidence demonstrates superior subjective and objective outcomes following anterior transvaginal polypropylene mesh as compared to anterior colporrhaphy (grade A). These outcomes did not translate into improved functional results using validated questionnaires or a lower reoperation rate for prolapse. The mesh group was also associated with longer operating time, greater blood loss and apical or posterior compartment prolapse as compared with anterior repair. Anterior polypropylene mesh had a mesh extrusion rate of 10.4% with 6.3% requiring a surgical correction (grade B). Single level 3 evidence does not support the use of transvaginal polypropylene mesh for recurrent anterior vaginal wall prolapse (grade C). Polypropylene anterior compartment mesh offers improved objective and subjective outcomes compared with native tissue repair; however, these benefits must be considered in the context of increased morbidity associated with anterior polypropylene transvaginal mesh.

Short-term surgical outcomes and characteristics of patients with mesh complications from pelvic organ prolapse and stress urinary incontinence surgery

Surgical treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can include the use of synthetic materials. Placement of synthetic materials into the vaginal wall, through either the vagina or the abdomen, includes the risk of complications such as vaginal wall extrusion or pain. There is little data regarding outcomes following treatment of mesh complications. A retrospective chart review of patients who underwent excision of mesh placed for POP or SUI between 1 January 2001 and 31 October 2012 was performed at the University of Virginia. Chart abstraction queried patient demographics, clinical history, physical examination, pre- and post-excision symptoms, and operative findings. The International Continence Society (ICS) and International Urogynecological Association (IUGA) classification system was used to define the nature and location of mesh complications. A total of 57 patients (26 mid-urethral slings, 23 transvaginal prolapse, 9 intraperitoneal prolapse) with the diagnosis of mesh extrusion into the vaginal wall were analyzed. Twenty-five (average 2.8 cases/year) original mesh surgeries occurred between January 2001 and January 2010 and 41 (average 20.5 cases/year) occurred after January 2010. The most common presenting patient complaints were chronic pelvic pain (55.9 %), dyspareunia (54.4 %), and vaginal discharge (30.9 %). At a 6-week post-operative visit, 57.3 % of patient's symptoms were completely resolved and 14.6 % were improved. Clinicians should be cognizant of the variable presentations of post-operative vaginal mesh complications. Mesh excision by experienced pelvic surgeons is an effective and safe treatment for these complications; however, a significant number of patients may have persistent symptoms following surgery.

Mesh Extrusion Through the Internal Cervical Os

Mesh extrusion or exposure is a known complication of procedures using synthetic mesh for vaginal vault and pelvic organ suspension. Preservation of the uterine cervix is thought to be protective against such complications, as the well-vascularized in situ cervix provides an added barrier between the mesh and the colpotomy incision, limiting potential exposure to the vaginal flora. We describe a case of a 55-year-old multipara, who presented with vaginal discharge following a supracervical hysterectomy with sacrocervicopexy and was found to have a delayed mesh extrusion though the endocervical os.

High risk of complications with a single incision pelvic floor repair kit: results of a retrospective case series

The aim of this study was to retrospectively assess the extent and severity of the post-operative complications associated with the Pinnacle Pelvic Floor Repair Kit. This is a descriptive analysis of 23 consecutive women who had a prolapse repair with either an anterior (n = 19) or posterior (n = 4) Pinnacle kit. The clinical records of all these patients were available for analysis. Pre-operative data and intra-operative complications were noted. All post-operative complications and repeat surgical interventions were recorded. In addition to pelvic floor symptoms, we looked specifically for pelvic pain and mesh contraction, exposure, extrusion or erosion. Complications were classified according to the joint IUGA/ICS system. Seventy percent (n = 16) of our cohort experienced at least one complication. All, except one, were following an anterior Pinnacle. 10 patients (43 %) had a tender vaginal mesh prominence, including a contraction band anteriorly or at the vaginal apex. Six (26 %) complained of associated buttock, groin or vaginal pain, while the tenderness was only detected during vaginal examination in 4 (16 %) patients. Three (13 %) patients required vaginal mesh excision for severe pain and one required a second procedure. Three patients (13 %) had vaginal mesh exposure and 8 (35 %) developed de novo stress incontinence. Two patients (8 %) developed symptomatic recurrent prolapse, one following mesh excision owing to large mesh exposure. Another patient had an anterior compartment prolapse above and below a tender contracted anterior vaginal mesh. The Pinnacle kit was associated with a high incidence of post-operative complications in this small series.

A Case of Silicone Mesh Extrusion Into the Bladder Associated With Robotic Sacrocolpopexy

Over the past several years, the daVinci robot has been used in gynecologic surgery as a new surgical approach. The literature is being slowly populated with pros and cons of this technology. We report a 60-year-old woman with a history of pelvic organ prolapse who had a robotic sacrocolpopexy. She presented with mesh extrusion into her vagina, which was removed by exploratory laparotomy. Two years later, she presented with mesh erosion into her bladder, which was removed. This case report provides an example of significant mesh complication associated with robotic sacrocolpopexy 4 years after surgery and then again 2 years later.

Vaginal approaches to pelvic organ prolapse repair

Changes in perception regarding the safety of mesh require a review of vaginal approaches for pelvic organ prolapse surgery with and without mesh. The purpose of this article is to examine the implications of the negative stigma toward mesh and review the outcomes of different vaginal approaches to pelvic organ prolapse repair. Defining a successful outcome of pelvic organ prolapse surgery from a symptomatic perspective instead of an anatomic perspective reveals that native tissue repairs and graft repairs are equivalent. In the posterior and apical compartments, a review of multiple studies shows that native tissue and graft transvaginal repairs have similar anatomic results except that native tissue repairs do not carry the risk of mesh extrusion. After failure of a native tissue repair, the majority of surgeons will use a graft-augmented repair. Controversy exists about how to define a successful outcome after pelvic organ prolapse surgery. Native tissue repairs require a more individualized approach than mesh-augmented repairs because native tissue requires the surgeon to closely examine the patient to determine the exact compartment and location that is affected before deciding on a surgical approach.

Is there any place for a transobturator approach for minisling surgery?

Dear Editor, I read with interest Naumann et al’s. article on Ajust in the International Urogynecology Journal [1]. At 2 years, 42/51 patients (82.4 %) had their continence fully restored. I write to draw readers’ attention to our 5-year randomized controlled trial study: “Tissue Fixation System (TFS) Minisling vs Transobturator Tape (TOT)” (n=80), as reported in 2012 in the Journal of Urology [2]. The TFS comprises a polypropylene, macroporous, monofilament mesh strip that has polypropylene soft-tissue anchors on each side, with a one-way tensioning system. The anchors were implanted retropubically, and the TOT was inserted by an outside/in technique. At 5 years, the objective cure rates for TFS and TOT were 83 % and 75 %, respectively (p=0.029). Mesh extrusion rate was low: one for each group. Nine from the TOT group (23 %) reported groin pain postoperatively. There were no reports of pain from the TFS group. It is interesting to note that patients with intrinsic sphincter deficiency (ISD) (<20 cm H2O on profilometry) were excluded from Naumann et al.’s study [1]. In his 2005 study (n=36), the first minisling reported in the literature, Petros [3] reported that 9/10 patients with ISD were 100 % dry postoperatively and one was 80 % improved. All results reported included the learning curve. The TFS is a tensioned sling, so it can be very precisely tensioned after implantation. It is also retropubic. Given the high cure rates for ISD reported with the retropubic TFS, the question needed to be asked is: “Is there any place for a transobturator approach for minisling surgery”?

Managing Complications of Implanted Mesh

The use of surgical mesh in gynecology has come under intense scrutiny over the past year. The US Food and Drug Administration released a public health notification in 2008 outlining the reported complications associated with mesh placement, followed by a safety communication update in 2011. Although implantation of any type of mesh can lead to complications, most are associated with transvaginal placement of mesh for the treatment of pelvic organ prolapse. This article briefly discusses the history of surgical mesh and how we arrived at our current inflection point. Standardized terminologies for describing mesh-related complications are reviewed. Lastly, management of common mesh-related complications are discussed, including the management of mesh extrusion and pelvic pain/dyspareunia.

Transvesical Laparoendoscopic Single Site Surgery to Remove Surgical Materials Penetrating the Bladder: Initial Clinical Experience in 9 Female Patients

The optimal approach for removing surgical materials that have penetrated the bladder is still debatable. We reviewed our initial experience with transvesical (percutaneous intraluminal access) laparoendoscopic single site surgery to treat such complications. We determined the safety, efficacy and morbidity of the procedure. In this case series study 9 women 24 to 63 years old were operated on from November 2009 to July 2012 due to bladder tape/mesh or surgical suture extrusion using the transvesical (percutaneous intraluminal access) laparoendoscopic single site surgery approach. We used the TriPort™ or TriPort+ single site access system, and a combination of straight and articulating or only standard laparoscopic instruments. A running V-Loc™ suture was placed as needed. In all cases followup included urine tests, abdominal ultrasound and cystoscopy. Mean operative time was 59 minutes (range 35 to 105). Median postoperative hospital stay was 2.4 days. No blood loss or complications were observed except 1 conversion to open surgery because of a perivesical abscess. No extra port was added. No adverse events related to the method were observed during the mean 19-month followup. In 1 patient mesh extrusion recurred after 12 months of followup. We consider this technique to be an efficient, safe procedure and a valuable minimally invasive treatment option for foreign body removal from the bladder. However, further observations are needed to prove the validity of the method.

Impregnation of implantable polypropylene mesh with S-nitrosoglutathione-loaded poly(vinyl alcohol)

Clinical complications of implantable polypropylene (PP) meshes used to repair urinary incontinence and vaginal prolapse may be associated with their low surface energy and consequent poor tissue integration. For improving tissue integration, we impregnated monofilament PP meshes with physically crosslinked poly(vinyl alcohol) (PVA), resulting in PVA deposits tightly attached inside the knot spaces of the PP knit. While preserving the mesh porosity, the PVA deposits acted as an array of hydrophilic regions leading to a great increase in the overall mesh wettability, reflected by a contact angle decrease from 111 to ca. 66°. The PVA deposits were also used as reservoirs for the local release of S-nitrosoglutathione (GSNO), a nitric oxide (NO) donor. Plain and impregnated PP meshes (1.0cm×1.0cm) were implanted in the subcutaneous tissue of 21 adult female Wistar rats. Histological analysis of the abdominal wall 21 days after the surgeries revealed lower edema and greater angiogenesis while a marked decrement of NOx concentration in the tissue surrounding the impregnated meshes was observed after 2 days. These results indicate that PVA and PVA/GSNO impregnation might be a new strategy for decreasing the frequency of mesh extrusion after PP mesh implants.

Prospective study of transobturator mesh kit (Prolift™) in pelvic reconstructive surgery with vaginal hysterectomy after 3 years’ follow-up

This study is to analyze prospectively the anatomical and functional outcomes of transvaginal pelvic reconstructive surgery using the Prolift™ system for pelvic organ prolapse (POP) with hysterectomy. A prospective, observational, noncomparative study was conducted in 80 patients with prolapse ≥ 2. Postoperative pelvic organ prolapse quantification stage was the main outcome measure. Anatomical cure was defined as vaginal vault stage 0 and improvement as stage 1. Secondary outcomes include pelvic floor distress inventory-20, incontinence impact questionnaire short form-7, and pelvic floor impact questionnaire short form-7. A total of 80 patients were recruited. The cure and improvement rates were 96.3 % (77/80) and 3.7 % (3/80) respectively at 1 year. At the follow-up of 3-years, the cure rates were 93.3 % (70/75). Among the five patients, three had stage 2 anterior wall prolapse, two had stage 2 posterior wall prolapse. Only one patient with intraoperative adverse event (rectal perforation) was encountered. Postoperative complications included prolonged catheterization in three patients (3.7 %), postoperative stress urinary incontinence in five patients (6.25 %) and asymptomatic mesh extrusions in five patients (6.25 %). All of them occurred within 1 year follow-up. Significant improvements in quality of life were detected at 1 and 3 years compared with baseline. The total Prolift™ system surgery represents a safe, simple and useful treatment for severe POP with satisfactory objective clinical outcomes.

A comparative study of onlay and retrorectus mesh placement in incisional hernia repair

Introduction: Incisional hernia after abdominal surgery is a well-known complication and the incidence of incisional hernias continues to be 2-11% after laparotomy. The repair of incisional hernia has always been a challenge to the surgeon. Various operative techniques for the repair of incisional hernia are in practice; however, the management is not standardized. The retro-rectus mesh placement or the sub-lay technique, popularized by Rives and Stoppa in Europe, has been reported to be quite effective, with low recurrence rates (0-23%) and minimal complications. Aims and Objective: The purpose of this study was to compare the traditional on-lay mesh and retro-rectus mesh placement in incisional hernia repairs in terms of time taken for surgery, early complications (wound infections, Mesh extrusion), and Delayed complications (Recurrence). Materials and Methods: This is a prospective study which was conducted in the surgical department of our hospital. A total of 50 cases were included in this study. Of these cases, 25 cases were operated by the on-lay mesh method and 25 by retro-rectus mesh placement. Only the patients with midline hernias up to 10 cm in diameter were included in the study. Result: The operative time for retro-rectus mesh placement was insignificantly higher than that of on-lay mesh repair, whereas, complications like superficial Surgical site infection SSI were identical in both the study groups, but deep SSI leading to infection of mesh was higher in on-lay mesh repair. The recurrence rate was found to be 4% in on-lay mesh repair and 0% in retro-rectus mesh repair. Conclusion: The follow-up period in this study was 6months; hence, late recurrences were not taken into account. However, the low rate of local complications and the low recurrence rate indicate that retro-rectus mesh repair has an advantage over traditional on-lay repair.

Transvaginal Mesh Kits—How “Serious” Are the Complications and Are They Reversible?

To review the merit of the U.S. Food and Drug Administration-issued warnings on the use of transvaginal mesh in women with pelvic organ prolapse because of escalating complications. On institutional review board approval, we reviewed the data from 2 tertiary institutions managing complications of transvaginal mesh. The data recorded included mesh type, details of surgical removal, and patient-reported clinical outcomes. From 2006 to March 2011, 58 women were evaluated. Their mean age was 54.6 years (range 32-80), with a mean follow-up of 13 months (range 6-67). The mean interval to mesh excision surgery from the original prolapse surgery was 21 months (range 2-60). Of the 58 women, 35 (60%) had undergone concurrent midurethral sling surgery with the transvaginal mesh surgery. Also, 21 of the 58 patients (36%) had undergone initial mesh removal attempts before their referral to either tertiary institution. Most women presented with multiple complaints, with mesh extrusion the most frequently reported (n=43 [74%]). Of the 58 women, 17 (29%) required re-excision of residual mesh, 13 once and 4 twice. Five women developed recurrent symptomatic pelvic organ prolapse (7%). The residual rate of dyspareunia and pelvic pain was 14% and 22%, respectively. Fourteen women (24%) were treated successfully, with complete resolution of all presenting symptoms. As outlined in the Food and Drug Administration notifications, patients should be forewarned that some transvaginal mesh complications are life altering and might not always be surgically correctable.