Mesh Revision Research Articles

The Impact of Smoking on Sacrocolpopexy Perioperative Outcomes: An Observational Study.

Tobacco smoke is a modifiable risk factor that surgeons discuss with patients prior to undergoing sacrocolpopexy or mesh revision surgery. The aim of the study was to investigate the effect of smoking on perioperative outcomes after sacrocolpopexy for pelvic organ prolapse and mesh revision repair. This was a retrospective cohort study of data obtained from the National Surgical Quality Improvement Project's database. Women who underwent surgery for pelvic organ prolapse via abdominal sacrocolpopexy (ASCP) or minimally invasive sacrocolpopexy (MISCP) or prolapse mesh revision surgery from 2011 to 2021 were identified and compared based on current tobacco use. Demographic, medical, and surgical history, as well as intraoperative and 30-day perioperative outcomes, were compared. Multivariate analysis was performed. Overall, 21,980 women underwent MISCP (8.60% smokers) and 3,775 underwent ASCP (8.74% smokers). Postoperative wound infections were more common after sacrocolpopexy in patients who smoked. Readmission after MISCP was more common in smokers. The composite perioperative morbidity score was different between smokers and nonsmokers for MISCP (P = 0.001) and ASCP (P = 0.002). Multivariate analyses of MISCP outcomes found an association between smoking and wound infection, readmission, and composite score. Multivariate analyses of ASCP outcomes found an association between smoking and wound infection. Overall 2,160 patients underwent mesh removal by any modality (16.57% smokers), and no difference in perioperative outcomes between smokers and nonsmokers for mesh removal was found. An association was found between tobacco smoking and wound infection as well as other postoperative complications. Tobacco use prior to a mesh excision procedure does not appear to increase perioperative outcomes.

MP07-10 BEFORE AND AFTER THE BAN: NATIONAL INCIDENCES OF TRANSVAGINAL MESH PLACEMENT AND REMOVAL FOR PELVIC ORGAN PROLAPSE

You have accessJournal of UrologyCME1 Apr 2023MP07-10 BEFORE AND AFTER THE BAN: NATIONAL INCIDENCES OF TRANSVAGINAL MESH PLACEMENT AND REMOVAL FOR PELVIC ORGAN PROLAPSE Elie Kaplan-Marans, Mariela Martinez, Arshia Sandozi, Jeffrey Lee, Dhaval Jivanji, Karis Buford, and Allison Polland Elie Kaplan-MaransElie Kaplan-Marans More articles by this author , Mariela MartinezMariela Martinez More articles by this author , Arshia SandoziArshia Sandozi More articles by this author , Jeffrey LeeJeffrey Lee More articles by this author , Dhaval JivanjiDhaval Jivanji More articles by this author , Karis BufordKaris Buford More articles by this author , and Allison PollandAllison Polland More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In April 2019, the Food and Drug Administration (FDA) banned manufacturers from selling and distributing mesh for transvaginal repair of pelvic organ prolapse (POP). We assessed national incidences of transvaginal mesh placement and revision or removal for POP before and after the ban. METHODS: The Medicare Physician and Other Practitioners database was queried for all transvaginal mesh placements and revisions or removals for POP between 2013 and 2020 using CPT codes 57267 and 57295, respectively. Linear regression was performed with statistical significance set to 95% confidence intervals. RESULTS: A total of 51,234 mesh placements and 15,854 mesh revisions or removals were identified. As shown in the Figure 1, there was a significant and gradual downward trend in utilization of both procedures during the study period, without precipitous changes after the ban (mesh placement, R2=0.97, p<0.001; mesh revisions or removals, R2=0.97, p<0.001). From 2013 to 2020, mesh placement decreased from 10,397 to 2,813 cases (370%) and mesh revision or removal decreased from 2,975 to 1,091 cases (270%). Despite the FDA ban, transvaginal mesh placement for POP was still performed in 2020 (2,813 cases). CONCLUSIONS: There was not a precipitous decline in the use of transvaginal mesh for prolapse after the 2019 ban. Utilization has instead gradually decreased since the original FDA notification in 2011. Physicians may now be using the remaining stock of transvaginal mesh or other types of mesh that are off-label for prolapse repair. It is important to discuss the risks and benefits of using transvaginal mesh as well as the FDA notification and ban with patients prior to prolapse surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e88 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elie Kaplan-Marans More articles by this author Mariela Martinez More articles by this author Arshia Sandozi More articles by this author Jeffrey Lee More articles by this author Dhaval Jivanji More articles by this author Karis Buford More articles by this author Allison Polland More articles by this author Expand All Advertisement PDF downloadLoading ...

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair

PurposeWith this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery.MethodsClinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction.ResultsThe multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified.ConclusionA longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

8681 Complications Among Patients Undergoing Mesh Graft Revision Surgery: A Retrospective Cohort Study of the NSQIP Database

<h3>Study Objective</h3> To compare complication rates among patients having urogynecology surgery for revision of a mesh graft placed for management of pelvic organ prolapse. <h3>Design</h3> A retrospective, population-based cohort study was conducted using the American College of Surgeons National Quality Improvement Program (NSQIP) database. A multivariable logistic regression analysis adjusting for age, race, smoking status, ASA category and concomitant procedures was completed. The outcomes were a composite of complications excluding urinary tract infections (UTI), and hospital readmission within 30 days. <h3>Setting</h3> Inpatient and outpatient mesh revision surgeries performed at community and academic hospitals captured in the NSQIP database from 2012 to 2019. <h3>Patients or Participants</h3> Patients undergoing mesh graft revision by urology or gynecology were classified into vaginal, abdominal or laparoscopic approach using Common Procedural Technology (CPT) codes. Patients having revision of a mid-urethral sling were excluded. <h3>Interventions</h3> Mesh graft revision surgery by vaginal, abdominal or laparoscopic approach <h3>Measurements and Main Results</h3> Of 1692 eligible patients, 1561 underwent vaginal, 74 underwent abdominal, and 57 underwent laparoscopic approach graft revision. The complication rate, excluding UTI, was 4.6% in the vaginal approach group, 12.2% in the abdominal approach group and 12.3% in the laparoscopic approach group (p<0.001). Compared to a vaginal approach, the abdominal approach group had higher odds of complications (abdominal: adjusted OR 2.76, 95% CI 1.30 – 5.83; laparoscopic: adjusted OR 1.86, 95% CI 0.73 – 4.72). The abdominal and laparoscopic groups had higher odds of readmission compared to the vaginal approach group (abdominal: adjusted OR 3.11, 95% CI 1.15 – 8.40; laparoscopic: adjusted OR 6.57, 95% CI 2.22 – 19.40). Clavien-Dindo IV complications were rare and only seen after vaginal surgery (0.4%, n=6). <h3>Conclusion</h3> Short term complications were uncommon after vaginal mesh graft revision surgery, and less common than following an abdominal approach.

Therapy of chronic extensor mechanism deficiency after total knee arthroplasty using a monofilament polypropylene mesh.

IntroductionLesions of the quadriceps or patellar tendon after total knee arthroplasty (TKA) are a rare but serious complication which, if left untreated, can lead to loss of function of the knee joint. While acute and subacute extensor mechanism disruptions may have several causes, chronic deficiencies are often related to multiple prior revision surgeries for joint infection or aseptic TKA failure. Up to date, biological allograft reconstruction showed unsatisfying results. The use of a monofilament polypropylene mesh is a promising approach for this pathological condition. The aim of the present study was to evaluate clinical, functional and patient reported outcomes of this procedure in patients with chronic extensor mechanism deficiency.Materials and MethodsTwenty-eight patients with chronic extensor mechanism deficiency (quadriceps tendon rupture n = 9, patellar tendon rupture n = 19) after TKA were included in this retrospective study. None of the patients were lost to follow-up. Surgical reconstruction was performed at one institution between 2014 and 2020 with a monofilament polypropylene mesh (Marlex Mesh, Bard, Murray Hill, USA). The mean age at the time of surgery was 69 years. Patients presented with a mean BMI of 33 kg/m2. The mean follow-up period was 23 months.ResultsThe 2-year survivorship free of mesh revision was 89% [95% confidence interval (CI): 75% to 100%]. Three patients (11%) had to undergo revision because of mechanical mesh failure and received another polypropylene mesh. No further revisions were performed thereafter. Flexion was 87° (range, 30–120°) on average. The majority of patients (75%, 21/28) had a full active extension. The mean active extension lag after surgery was 4 degrees (range, 0–30°).DiscussionWe observed a substantial improvement of extensor mechanism function. The majority of patients had full extension and showed good clinical results. A failure rate of over 50% has been published for alternative procedures. Thus, the use of the described augmentation technique represents a reasonable treatment option for chronic extensor mechanism disruptions of the patellar tendon as well as the quadriceps tendon after total knee arthroplasty. However, there might be a potentially higher risk for infection persistence in periprosthetic joint infection cases due to the presence of a foreign material.

Establishing the Queensland Pelvic Mesh Service: Preliminary experience.

Transvaginal mesh (TVM) has been used for treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Mesh-related complications are reported in 3% of women receiving mid-urethral sling surgery for SUI and in up to 20% of women who receive TVM for POP. The Australian Senate Enquiry report in March 2018 recommended that each Australian state establish specialist multidisciplinary units for management of TVM complications. The aims of this study are to report on the setting up of the Queensland Pelvic Mesh Service (QPMS) and summarise its first 24months to provide a potential framework for the establishment of similar service models within Australia and internationally. The planning and implementation of QPMS was a complex two-stage co-design process involving clinicians and consumers representing women with TVM complications. Consumer input in planning was important for the optimal establishment of QPMS to meet women's holistic needs. From April 2019 to April 2021, 484 women had been treated by the medical team; 257 women had undergone cystoscopy and examination under anaesthesia; 91 patients had undergone mesh revision surgery - 65 complete excision and 25 partial excision and one sling division; and 180 women had been discharged from QPMS. Providing a comprehensive multidisciplinary service for managing TVM complications requires careful planning with consumer involvement before initiation. Addition of these patients to an existing service may not succeed. Emphasis on surgery may be misplaced for many. QPMS patients, as in sufferers with chronic pain conditions, benefit from psychological support and allied healthcare.

O23 SURGICAL REPAIR OF PARASTOMAL BULGING - A REGISTER-BASED STUDY

Abstract Aim To examine the incidence of primary and recurrent repair and types of repair performed in patients with parastomal bulging. Material and Methods We linked prospectively collected data on parastomal bulging from the Danish Stoma Database to surgical data on repair of parastomal bulging from the Danish National Patient Register. Survival statistics provided cumulative incidences and time until primary and recurrent repair Results Of 1016 patients, registered from 2010-2017 with a permanent stoma and a parastomal bulge, 180 (18%) underwent surgical repair. The cumulative incidence of a primary repair was 9% (95% CI [8%; 11%]) within 1 year and 19% (95% CI [17%; 22%]) within 5 years after the occurrence of a parastomal bulge. For colostomies and ileostomies, we found similar probability of undergoing primary repair. For recurrent repair, the 5-year cumulative incidence was 5% (95% CI [3%; 7%]). The probability of undergoing further recurrent repair was 33% (95% CI [21%; 46%]) within 5 years. For primary repair, open or laparoscopic repair with mesh (43%) and stoma revision (39%) were performed almost equally frequent. Stoma revision and repair with mesh could precede and follow one another as primary and recurrent repair. Stoma reversal was performed in 17% of patients. Conclusions Our data offered a new and comprehensive view of the course of surgical treatment of parastomal bulging. Five years after the occurrence of a parastomal bulge the estimated probability of undergoing a repair was 19%. The probability of undergoing recurrent repair was high and stoma reversal more common than expected.

MP52-05 REVISION OF THE MIDURETHRAL SLING IS NOT PROBLEM-FREE: QUANTIFYING COMPLICATIONS OF REVISION SURGERY USING THE CLAVIEN-DINDO CLASSIFICATION SYSTEM

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II (MP52)1 Sep 2021MP52-05 REVISION OF THE MIDURETHRAL SLING IS NOT PROBLEM-FREE: QUANTIFYING COMPLICATIONS OF REVISION SURGERY USING THE CLAVIEN-DINDO CLASSIFICATION SYSTEM Hailey Silverii, Yu Zheng, Nicholas Major, Phillip Latham, Parker McDuffie, Lindsey Cox, Ross Rames, and Eric Rovner Hailey SilveriiHailey Silverii More articles by this author , Yu ZhengYu Zheng More articles by this author , Nicholas MajorNicholas Major More articles by this author , Phillip LathamPhillip Latham More articles by this author , Parker McDuffieParker McDuffie More articles by this author , Lindsey CoxLindsey Cox More articles by this author , Ross RamesRoss Rames More articles by this author , and Eric RovnerEric Rovner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002082.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although highly successful for the treatment of stress urinary incontinence, revision surgery for the midurethal sling (MUS) may be indicated in cases of postoperative obstruction, pain, exposure, and/or erosion. Such reoperative cases can challenging, and have inherent risks of unique complications which have not been well characterized. We describe and categorize complications using the Clavien-Dindo classification system in a large series of patients who underwent MUS revision. METHODS: Following IRB approval, we retrospectively reviewed the records of 293 patients who underwent MUS revision with or without a concomitant sling between 2008 and 2020 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were documented within a 90 day post-operative period. MUS technique, concomitant POP mesh procedures, and medical comorbidities were assessed. RESULTS: Of the 293 patients who underwent revision surgery following synthetic MUS placement, 66.5% (n=195) of patients experienced at least one complication post operatively. 41.6% (n=127) of patients also had concomitant transvaginal prolapse mesh revision surgery. 300 complications were identified in total. 30% (n=87) were classified as Grade I with the most common being persistent urge urinary incontinence (UUI) (36.8%; n=32), de novo stress urinary incontinence (SUI) (28.7%, n=25), and urinary retention (26.4%, n=23). 54% (n=158) of these were Grade II with the most common of these being urinary tract infection (UTI) (48.1%, n=76) and vaginal yeast infection (19%, n=31). 10% (n=29) of complications were identified as Grade IIIb, and 3 (1%) were Grade IVa complications. There were no Grade IVb or V complications. Concomitant POP mesh placement and retropubic or transobturator MUS were not associated with increased complications based on Clavien-Dindo classification. CONCLUSIONS: Mesh revision surgery is associated with a high frequency of minor complications with a low but not insignificant incidence of more severe complications. These findings underline the importance of sufficient counseling of patients regarding expectations, and risks of MUS revision surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e931-e932 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hailey Silverii More articles by this author Yu Zheng More articles by this author Nicholas Major More articles by this author Phillip Latham More articles by this author Parker McDuffie More articles by this author Lindsey Cox More articles by this author Ross Rames More articles by this author Eric Rovner More articles by this author Expand All Advertisement Loading ...

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery.

To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery. Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on thepatient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

Efficacy of surgical revision of mesh complications in prolapse and urinary incontinence surgery

Introduction and hypothesisWomen with mesh-related complications in prolapse (POP) and stress-urinary incontinence (SUI) surgery may benefit from operative mesh resection to alleviate symptoms. We hypothesized that mesh resection would alleviate symptoms and aimed to evaluate risks and benefits in these women.MethodsWe carried out a cross-sectional study. Primary outcome was improvement specified as better, unchanged or worsened symptoms after mesh revision surgery. Secondary outcomes were health-related quality of life (HrQol) scores of validated questionnaires, surgical characteristics and physical findings at follow-up visits. Descriptive data were reported with mean and medians. Associations were calculated with Spearman correlation coefficient and chi-square test to determine statistical differences between groups.ResultsFifty-nine women who underwent mesh revision surgery between 2009 and 2016 were included. After a median follow-up of 1.7 (IQR: 1.1–2.4) years, 44 women (75%) reported improvement of symptoms. No significant surgical or patient characteristics were identified that could differentiate which patients did or did not experience cure or complications.A trend was observed to better HrQol scores in women who reported overall improvement after mesh revision surgery. Seventeen (29%) women needed a subsequent operation after mesh removal.ConclusionsThis cross-sectional study shows that mesh revision surgery alleviates symptoms in 75% of women with mesh-related complications. Type of revision surgery and individual characteristics did not seem to matter to the individual chance of cure or complications. These data can facilitate the counseling of women considering mesh revision surgery.

Management of mesh complications following surgery for stress urinary incontinence or pelvic organ prolapse: a systematic review.

Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. Search strategies were developed for each indication for referral. Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.

Long-term Risk of Reoperation After Synthetic Mesh Midurethral Sling Surgery for Stress Urinary Incontinence.

To measure the long-term reoperation risk after synthetic mesh midurethral sling surgery. This retrospective cohort study evaluated all patients who underwent a midurethral sling surgery for stress urinary incontinence (SUI) (2005-2016) within a large managed care organization of 4.5 million members. We queried the system-wide medical record for Current Procedural Terminology and International Classification of Diseases, 9 or 10 Revision codes for patient data, and implant registry coding to assess the sling type. The primary outcome was the overall reoperation rate after midurethral sling, with secondary outcomes being reoperation for mesh revision, or removal and recurrent SUI. We used cumulative incidence to calculate reoperation risk as a function of time at least 1 year, least 5 years, and at least 9 years. We compared demographics, characteristics, and reoperation of patients using χ and Wilcoxon rank sum, and we used a Cox proportional hazards model to calculate adjusted hazard ratios. In this cohort of 17,030 patients treated with primary midurethral slings, the overall reoperation rate was 2.1% (95% CI 1.9-2.4%) at 1 year, 4.5% (95% CI 4.1-4.8%) at 5 years, and 6.0% (95% CI 5.5-6.5%) at 9 years. Risk of reoperation was affected by race (P=.04), with Asian or Pacific Islander patients having a lower reoperation rate when compared with white patients. Reoperation rate for mesh revision or removal was 0.7% (95% CI 0.6-0.8%) at 1 year, 1.0% (95% CI 0.8-1.1%) at 5 years, and 1.1% (95% CI 0.9-1.3%) at 9 years. Reoperation for recurrent SUI was 1.6% (95% CI 1.4-1.8%) at 1 year, 3.9% (95% CI 3.5-4.2%) at 5 years, and 5.2% (95% CI 4.7-5.7%) at 9 years. Risk of reoperation for recurrent SUI was affected by the type of sling, with reoperation more common after single-incision compared with retropubic sling (adjusted hazard ratio 1.5 [95% CI 1.06-2.11] P=.03). Midurethral slings have a low long-term risk of reoperation for mesh revision or removal, and recurrent SUI, adding to the evidence of their safety and efficacy for the treatment of women with SUI.

Association between method of pelvic organ prolapse repair involving the vaginal apex and re-operation: a population-based, retrospective cohort study.

Vaginal apical suspension is essential for the surgical treatment of pelvic organ prolapse (POP). We aim to evaluate whether the method of apical repair is associated with different re-operation rates for POP recurrence or surgical complications. Population-based, retrospective cohort study of all Ontario women receiving primary apical POP repairs from 2003 to 2015. Primary exposure was the method of apical POP repair. Primary outcome was re-operation for recurrent POP, and secondary outcomes were surgical procedures for genito-intestinal (GI) or genitourinary (GU) complications, fistula repair, and mesh revision or removal. Forty-three thousand four hundred fifty-eight women were included. Overall, the number of mesh-based apical repairs decreased over time, while the number of native-tissue repairs slightly increased (p < 0.001). Multivariable Cox proportional hazards (Cox PH) analysis demonstrated a significant increase in repeat POP operations for transvaginal mesh apical repairs (adjusted HR 1.28 [95% CI: 1.10-1.48]), but not in abdominal mesh repairs (adjusted HR 0.96 [95% CI: 0.81-1.13]) compared with vaginal native tissue apical repairs. Overall risk of repeat surgery for fistulas or GI and GU complications remained low (< 0.5%). Risk of mesh removal or revision was 11.5-11.9%, with no difference between abdominal versus vaginal mesh on multivariable analysis (adjusted HR 0.99 [95% CI: 0.78-1.26]). Re-operation for recurrent POP is highest in transvaginal mesh apical repairs; however, this risk did not differ between abdominal mesh and vaginal native tissue apical repairs. GI and GU re-operations are rare. There is no difference in mesh removal or revision rates between abdominal and vaginal mesh repairs.

Extensor Mechanism Reconstruction with Use of Marlex Mesh: A Series Study of 77 Total Knee Arthroplasties.

Disruption of the extensor mechanism after total knee arthroplasty (TKA) is debilitating, and the reported results of numerous reconstructive options have varied. We previously reported the early results of 13 patients who underwent reconstruction of the extensor mechanism with use of Marlex mesh. The purpose of the current study was to assess results in a larger cohort of patients, with an emphasis on the survivorship of the mesh, clinical results, and complications. During the period of 2000 to 2015 at a single tertiary care academic institution, 77 patients (77 TKAs) underwent reconstruction with use of Marlex mesh for an extensor mechanism disruption (27 quadriceps tendon disruptions, 40 patellar tendon disruptions, and 10 patellar fractures). The mean patient age at the time of reconstruction was 65 years; 70% of the patients were female. The mean body mass index was 35 kg/m. The mean follow-up was 4 years. Eighteen (23%) of the patients underwent mesh reconstruction with the primary TKA in place, and 59 (77%) had mesh reconstruction at the time of revision TKA. The mean time between disruption and reconstruction was 7 months. Twenty (26%) of the patients had previously undergone attempted extensor mechanism reconstruction at outside institutions. Sixty-five of the 77 mesh reconstructions were in place at the time of the latest follow-up. Twelve patients experienced a failure that required mesh revision: 5 for patellar tendon rupture, 5 for quadriceps tendon rupture, and 2 for symptomatic lengthening. Four additional patients with mesh failure were treated nonoperatively with bracing. The 2-year survivorship free of mesh revision was 86% for patients with no prior reconstruction and 95% for patients with previous reconstructions of the extensor mechanism that did not involve Marlex mesh. Knee Society Score (KSS) results significantly improved following reconstruction (p < 0.001). Extensor lag improved by a mean of 26°, with mean postoperative extensor lag measuring 9° (p < 0.001). Reconstruction of the extensor mechanism with use of Marlex mesh is a viable option in patients with catastrophic disruption after TKA. At the time of the latest follow-up, 84% of the mesh reconstructions were in place and the functional outcomes were excellent, with mean improvement in extensor lag of 26°. Extended follow-up is required, but the results of this large series with a mean follow-up of 4 years are encouraging. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Functional outcomes of synthetic tape and mesh revision surgeries: a monocentric experience.

Synthetic tapes and meshes used for the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can lead to complications that require additional surgical procedures. The objective of this study was to report the functional outcomes following tape/mesh removal procedures. This retrospective study included all consecutive women who underwent a tape/mesh surgical revision in a single tertiary referral center from January 2008 to September 2016. Descriptive statistics were performed to assess outcomes. Overall 140 women, with a mean age of 60.5 (range 35-91) years, had a tape/mesh surgical revision. Patients underwent the following surgeries: tape removal (n = 95/140, 67.9%), tape division (n = 23/140, 16.4%), mesh removal (n = 18/140, 12.9%) and concomitant tape and mesh removal (n = 4/140, 2.9%). Tape removals were mainly performed for voiding symptoms (n = 34/95, 35.8%) and vaginal erosion/extrusion (n = 16/95, 16.8%). Most mesh removals were performed for vaginal erosion/extrusion (n = 9/18, 50.0%). Mean interval between tape/mesh insertion and its surgical revision was 52.1months (range 5.0days-16.0years). Mean follow-up time was 20.4months (range 6.0days-7.8years). Voiding and storage symptoms resolved completely in 37/59 (62.7%) patients and in 14/37 (37.8%) patients, respectively; 42/81 (51.9%) patients with postoperative SUI recurrence or persistence underwent an additional surgical procedure. Among the 18 patients who had a mesh removal, only 1 (5.6%) had POP recurrence. Although most symptoms resolved after tape and mesh surgical revisions, patients must be informed that symptoms may persist. Recurrent or persistent SUI or POP may require a subsequent surgical procedure.

MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION?

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy III1 Apr 2018MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION? Elizabeth Dray, Anne Pelletier Cameron, Erin Crosby, Ashley Grable, J Quentin Clemens, John Stoffel, Priyanka Gupta, and Paholo Barboglio-Romo Elizabeth DrayElizabeth Dray More articles by this author , Anne Pelletier CameronAnne Pelletier Cameron More articles by this author , Erin CrosbyErin Crosby More articles by this author , Ashley GrableAshley Grable More articles by this author , J Quentin ClemensJ Quentin Clemens More articles by this author , John StoffelJohn Stoffel More articles by this author , Priyanka GuptaPriyanka Gupta More articles by this author , and Paholo Barboglio-RomoPaholo Barboglio-Romo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2094AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Synthetic mid-urethral slings (MUS) are the most commonly performed treatment for stress urinary incontinence in women. While these procedures are typically safe and effective, complications do occur. The goal of our study was to define the presentation and outcomes of patients who underwent revision/removal of synthetic MUS at our institution. METHODS We performed a retrospective review of 432 women who underwent revision of a synthetic mid-urethral sling at our institution between 2005 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from our analysis. The outcomes assessed were AUA SI, Michigan Incontinence Symptom Index (M-ISI), pad use and post-void residual (PVR). RESULTS Average patient age was 53 and parity was 2.5. The majority of patients had a TVT (172) followed by TOT (182) and minisling (40). The remainder of slings were MUS of unidentified type. Eighty-one patients had undergone prior mesh revisions elsewhere. Patients presented with four primary complaints: mesh exposure or erosion, pain or dyspareunia, incontinence and bladder outlet obstruction. Most patients presented with at least two categories of mesh-related complaints, with the most common presentations being incontinence/pain (84 patients) and mesh exposure/pain/incontinence (74 patients). Patients most commonly underwent partial or complete excision of the vaginal portion of their mesh (110 and 248 patients respectively). Multiple mesh revisions were performed on 43 patients. Average follow-up was 14 months. The majority of patients (302) did not require further incontinence procedures at our institution. Forty-one patients had a sling placed at the time of mesh revision and 89 patients underwent procedures for incontinence at a later date. Clinically and statistically significant improvement was demonstrated on both validated questionnaires postoperatively. The number of patients reporting pain or dyspareunia declined (p<0.001), as well as the number reporting incontinence of any kind (p=0.006). PVR improved from a preoperative average of 91 cc to 48 cc postoperatively (p=0.001) and average pad use improved from 2.1 pads per day to 1.5 pads per day(p=0.003). CONCLUSIONS Despite complex patient presentations, subjective and objective urologic symptom measures significantly improve following MUS revision. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1008 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Elizabeth Dray More articles by this author Anne Pelletier Cameron More articles by this author Erin Crosby More articles by this author Ashley Grable More articles by this author J Quentin Clemens More articles by this author John Stoffel More articles by this author Priyanka Gupta More articles by this author Paholo Barboglio-Romo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes and Characteristics of Patients Undergoing Surgical Management for Mesh Related Complications.

The aims of this study were to describe the characteristics of women presenting with mesh-related complications and evaluate postoperative quality of life, sexual functioning, and patient-perceived outcomes. This institutional review board-approved study included a retrospective chart review and a cross-sectional follow-up with validated questionnaires. Demographics and medical histories were collected from charts of women treated for mesh-related complaints between 2010 and 2014. Subjects completed follow-up validated questionnaires regarding health, sexual functioning, postoperative symptom improvement/severity, satisfaction, and regret with the decision to pursue treatment. Ninety-three charts were analyzed. Mean subject age was 55 years, median body mass index was 28.7 kg/m, and median time from mesh placement to presentation was 2.7 years. Forty-nine had midurethral sling mesh only, 30 had prolapse-related mesh, and 14 had both. Forty-two subjects (48.9%) had mesh exposures, 19 involving prolapse-related mesh (52.4% transvaginal and 47.4% sacrocolpopexy). Surgical revisions were most often for exposure and pain. Seventy-five women were reached for follow-up; 71 agreed to participate, 53 (75%) returned the questionnaires. Thirty had sling revision, 22 had prolapse mesh revision, and 1 had both. Questionnaire results revealed no changes in health or sexual function after treatment. Postoperatively, subjects reported symptom improvement, low symptom severity, as well as high satisfaction and low regret with the decision to pursue surgical intervention. Women with mesh complications presented 2 years after initial placement, most often complaining of exposure or pain/dyspareunia. Although no changes in health or sexual functioning were noted postoperatively, participants reported symptom improvement after revision and satisfaction with the decision to pursue treatment.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System

We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery. With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed. Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications. Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery.

This document focuses on the management of complications related to mesh used to correct stress urinary incontinence or pelvic organ prolapse. Persistent vaginal bleeding, vaginal discharge, or recurrent urinary tract infections after mesh placement should prompt an examination and possible further evaluation for exposure or erosion. A careful history and physical examination is essential in the diagnosis of mesh and graft complications. A clear understanding of the location and extent of mesh placement, as well as the patient's symptoms and therapy goals, are necessary to plan treatment approaches. It is important that a treating obstetrician-gynecologist or other gynecologic care provider who seeks to revise or remove implanted mesh be aware of the details of the index procedure. Diagnostic testing for a suspected mesh complication can include cystoscopy, proctoscopy, colonoscopy, or radiologic imaging. These tests should be pursued to answer specific questions related to management. Given the diverse nature of complications related to mesh-augmented pelvic floor surgery, there are no universal recommendations regarding minimum testing. Approaches to management of mesh-related complications in pelvic floor surgery include observation, physical therapy, medications, and surgery. Obstetrician-gynecologists should counsel women who are considering surgical revision or removal of mesh about the complex exchanges that can occur between positive and adverse pelvic floor functions across each additional procedure starting with the device implant. Detailed counseling regarding the risks and benefits of mesh revision or removal surgery is essential and can be conducted most thoroughly by a clinician who has experience performing these procedures. For women who are not symptomatic, there is no role for intervention.

Committee Opinion No. 694 Summary: Management of Mesh and Graft Complications in Gynecologic Surgery.

This document focuses on the management of complications related to mesh used to correct stress urinary incontinence or pelvic organ prolapse. Persistent vaginal bleeding, vaginal discharge, or recurrent urinary tract infections after mesh placement should prompt an examination and possible further evaluation for exposure or erosion. A careful history and physical examination is essential in the diagnosis of mesh and graft complications. A clear understanding of the location and extent of mesh placement, as well as the patient's symptoms and therapy goals, are necessary to plan treatment approaches. It is important that a treating obstetrician-gynecologist or other gynecologic care provider who seeks to revise or remove implanted mesh be aware of the details of the index procedure. Diagnostic testing for a suspected mesh complication can include cystoscopy, proctoscopy, colonoscopy, or radiologic imaging. These tests should be pursued to answer specific questions related to management. Given the diverse nature of complications related to mesh-augmented pelvic floor surgery, there are no universal recommendations regarding minimum testing. Approaches to management of mesh-related complications in pelvic floor surgery include observation, physical therapy, medications, and surgery. Obstetrician-gynecologists should counsel women who are considering surgical revision or removal of mesh about the complex exchanges that can occur between positive and adverse pelvic floor functions across each additional procedure starting with the device implant. Detailed counseling regarding the risks and benefits of mesh revision or removal surgery is essential and can be conducted most thoroughly by a clinician who has experience performing these procedures. For women who are not symptomatic, there is no role for intervention.