Transvaginal Mesh Revision Surgeries
Transvaginal mesh is designed to be a permanent treatment for pelvic organ prolapse or stress urinary incontinence. However, mesh implants are associated with several complications. Some of those complications require intensive revision surgery, and many patients require multiple surgeries to completely remove mesh.
Revision surgery is a surgery to remove or repair transvaginal mesh implants. Because manufacturers designed the medical devices to be permanent, surgery to remove them is complex and often more painful than the initial mesh procedure.
Mesh survivor Tammy Jackson told Drugwatch that removing mesh is like “trying to remove gum from hair.” Jackson underwent surgery to partially remove a mesh implant she had received for stress urinary incontinence, or SUI.
There is no guarantee that revision surgery will correct all mesh symptoms. For example, Jackson still suffers from pain, infections and other problems.
“Transvaginal mesh revision(s) for complications generally have a positive effect on pain outcomes, but better control studies are needed.”
“Transvaginal mesh revision(s) for complications generally have a positive effect on pain outcomes, but better control studies are needed,” Stephen Mock and colleagues wrote in the Lower Urinary Tract Symptoms journal.
General surgeons, gynecological surgeons or urogynecologists, which are specialists with extra training to treat pelvic floor disorders, may perform the surgery.
Deciding on Revision Surgery
The type of mesh complication and its severity determine the type of revision surgery. The type of mesh used usually determines how many procedures are necessary to remove it. Some women who filed lawsuits against mesh manufacturers have had more than 10 surgeries to remove mesh.
- Bowel or bladder obstruction
- Erosion (also called exposure, extrusion or protrusion)
- Fistula (an unnatural connection between organs, such as the vagina and rectum)
- Injuries to blood vessels
- Injuries to bowel or bladder (perforation)
- Injuries to nerves
- Obstruction of the urethra
- Painful sex (dyspareunia)
- Vaginal constriction
Generally, women who’ve had a piece of mesh placed transvaginally to treat pelvic organ prolapse experience more severe, chronic and difficult-to-treat complications compared to women who’ve had a mesh sling implanted, Dr. Sara Abbott and colleagues wrote in an article published in the American Journal of Obstetrics & Gynecology in 2014.
The researchers followed 347 women who sought help for mesh complications from January 2006 to December 2010 in four different centers in the United States. Seventy-seven percent of the women had a grade three or four complication, which is classified as severe.
Of the women studied:
- 30 percent reported pain during sex
- 42.7 percent suffered mesh erosion
- 34.6 percent complained of pelvic pain
The Food and Drug Administration defines mesh erosion as a complication that occurs when mesh erodes through tissue and becomes exposed. The complication is also called exposure, extrusion or protrusion. Vaginal mesh erosion is the most common mesh-related complication experienced by patients who undergo transvaginal POP repair with mesh, according the FDA.
Surgical options range from trimming mesh to completely removing the implant. Approximately 275 women evaluated in Abbott’s study needed surgery. Roughly 72 women required more than one surgery.
The study detailed five types of revision surgeries doctors had chosen as the first surgical procedure to manage mesh complications:
- 138 women underwent trimming of mesh that had eroded tissue
- 49 women had surgery to release the “arms” of mesh, which involved making incisions to release tension
- 73 women had complete mesh removal
- 63 women had surgery for recurrent prolapse
- 40 women had surgery for recurrent incontinence
- 56 women had an unspecified surgery
Most surgeons believe that removal of the entire mesh is not necessary, said Dr. Gopal H. Badlani, professor and vice chair of urology at Wake Forest School of Medicine.
“You just remove the portion that’s exposed with a rim of tissue around it, and then you mobilize the flap of the vaginal wall to cover that defect and that suffices in most patients,” he said, “and that’s a very small outpatient procedure in most cases.”
Removing the entire mesh is more difficult, and there is a risk of injuring the adjacent organ.
“There are a few surgeons who believe in total meshectomy,” said Badlani, who estimates he performs roughly 20 surgeries a year to remove mesh or treat mesh-related complications. “Most of those cases are done for pain indications.”
The FDA has stated that complications from mesh are not rare. Studies have indicated that mesh complications occur in 15 percent to 25 percent of patients, according to an article by Dimitri Barski and Donna Y. Deng in BioMed Research International. However, not all complications require revision surgery.
Because study sizes and facilities vary, there is no definitive mesh revision surgery rate. The experience of surgeons in a particular group may influence the rate of revision surgeries. In general, patients who go to surgeons who have specialized training and perform high volumes of transvaginal mesh surgeries may suffer fewer complications and be less likely to need revision.
A study by Dr. Blayne Welk and colleagues published in JAMA Surgery showed patients of surgeons who performed fewer mesh-based procedures annually were about 37 percent more likely to need revision surgery.
A study published by Daniel Altman and colleagues in the New England Journal of Medicine found 3.2 percent of 186 women who had received mesh for pelvic organ prolapse required revision surgery within one year.
A study published by Michele Jonsson Funk and colleagues in the American Journal of Obstetrics & Gynecology concluded 3.7 percent of 188,454 women who had received mesh slings required revision surgery after nine years.
A study published by Dr. Blayne Welk and colleagues in JAMA Surgery found roughly 3.3 percent of women may require revision surgery 10 years after stress urinary incontinence surgery.
An eight-year study of 92,246 participants published by Kim Keltie and colleagues in Scientific Reports found 5.9 percent of women who had had mesh procedures were readmitted to the hospital for further surgery within five years.
Outcomes of Mesh Removal
Doctors don’t rush to recommend revisions because corrective surgery is complex. The process to remove mesh is time-consuming, painful and difficult. It takes a skilled surgeon to remove pieces of fine mesh that have fused with nearby organs and tissues. There is no guarantee that symptoms will completely resolve.
Alison M. Parden and colleagues sent questionnaires to 115 women who had revision surgery for problems such as painful sex, general pain and vaginal erosion. They published their findings in the March 2017 issue of American Journal of Obstetrics & Gynecology.
Forty-three women responded to the questionnaires. Out of those women, only 51 percent were completely satisfied with their revision.
A study published in 2015 in the International Urogynecology Journal reported the health outcomes of 233 women who had surgery to remove mesh. Seventy-three percent reported their pain improved, according to the study’s author Jill M. Danford and colleagues.
Sometimes, a surgeon cannot remove mesh in its entirety because removing it may cause too much damage.
Janet Holt of San Antonio, Texas, experienced this problem when trying to remove her mesh. Within four years of her initial prolapse surgery, she underwent seven surgeries to remove it, according to an MSNBC.com article.
After the implant is removed, patients must deal with the original condition they had prior to mesh: prolapse or incontinence. Sometimes, it is worse. After doctors remove mesh, inflammatory responses may continue.
Surgeons may try to reconstruct eroded tissues with grafts or other tissues. A case study presented by Dr. Melissa L. Dawson and colleagues in Reviews in Urology described a procedure in which surgeons used the omentum — a large flap of tissue that hangs down from the stomach — to make repairs after mesh removal. The patient reported her symptoms improved.
Alternatives to Revision Surgery
Some doctors may recommend conservative treatments, such as antibiotics or vaginal creams. Physical therapy may help loosen tight muscles and pelvic scar tissue.
“There are a whole host of techniques that we use, and we do not use any cookbook methods, which means that we do not use the same techniques over and over on patients,” therapist Amy Robinson said in an episode of the Drugwatch Podcast.
- Connective tissue manipulation
- Myofascial release
- Sustained pressure
- Visceral manipulation
- Cranial sacral therapy
- Manual lymph drainage
- Wurn technique
But conservative treatments might just lead to the eventual need for surgery. Barski and Deng found 60 percent of patients who had initially been treated with conservative methods needed surgery later.
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