Predictors of prolonged hospitalization and perioperative complications following mid-urethral sling mesh removal.

PURPOSE: To assess preoperative and perioperative characteristics associated with increased length of stay and major complications after mid-urethral sling mesh removal. METHODS: We performed an IRB-approved retrospective analysis of patients who underwent mid-urethral sling mesh removal. Demographic data and baseline surgical characteristics were collected. Operative reports and hospital/clinic notes were reviewed for complications which were categorized using the Clavien-Dindo Classification scheme. Length of stay was deemed abnormal if greater than 1 day. Complications were assessed using multivariate regression analysis. RESULTS: A total of 468 patients were identified as having undergone mid-urethral sling mesh removal. Mean age was 56 (± 11.1). 431 patients had either retropubic or transobturator slings. 241 patients underwent retropubic or groin exploration as a part of their mesh removal. A prolonged length of stay was noted in 73 patients (15.6%) and 13 patients (2.8%) experienced a Clavien Grade 3 complication. Pre-operative narcotic/benzodiazepine use, concomitant surgical procedure, bladder injury, increased ASA class, and major complications had an increased odds of a prolonged length of stay. Patients who experienced a bladder injury, groin/suprapubic incision, and estimated blood loss of over 400 mL had an increased odds of Clavien Grade 3 complications. CONCLUSIONS: Patient characteristics and perioperative factors are associated with increased length of stay and major complications after mid-urethral sling mesh removal.

The Burden of Reoperations and Timeline of Problems in 1,530 Cases of Mesh-Related Complications.

BACKGROUND: Mesh-related complications resulting from pelvic organ prolapse (POP) reconstruction operations may be a devastating experience leading to multiple and complex interventions. OBJECTIVES: The aim of the study was to describe the experience and time frame of management of mesh-related complications in women treated for POP or stress urinary incontinence in a tertiary center. METHODS: 1,530 cases of mesh-related complications were accessed regarding their clinical presentation, number of surgeries, and timeline of surgical treatments to treat multiple clinical complaints until the ultimate operation where all the meshes were removed in a single tertiary center. RESULTS: The studied population revealed to be a highly referred one with only 10.2% of the cases implanted at our center. Clinical presentation varied widely with 48.7% referring pain as the chief complaint, while 31.3% complained of voiding dysfunctions, 2.5% reported genital prolapses, 2.2% complained of vaginal problems, and 1.2% noted intestinal problems as the main clinical complaint. Only 4.8% of the cases presented mesh erosion at examination; 57.8% of the cases required more than 1 operation to address the mesh-related problems. Sixty-eight cases had more than 10 operations up to complete removal. Three clusters of patients could be identified: (i)-those from whom the mesh was promptly removed after clinical problems emerged, (ii) those with slowly evolving problems, and (iii) those with escalating problems despite treatment attempts. CONCLUSIONS: Mesh-related complications after pelvic floor reconstruction are an evolving disease with diverse clinical presentation. The identified time-related problems and the multiple failed attempts to treat their complications warrant attention with continuous monitoring of these patients and aggressive removal of the mesh if the clinical complaint cannot be swiftly managed.

Robot-assisted laparoscopic sacrocolpopexy with autologous fascia lata: technique and initial outcomes.

INTRODUCTION AND HYPOTHESIS: Pelvic reconstructive surgery is increasingly being performed with autologous grafts to avoid complications of synthetic mesh and improve the durability of a native tissue repair. Autologous fascia lata (AFL) provides a reliable source of robust connective tissue to improve surgical outcomes. We present our technique and initial experience with performing robotic sacrocolpopexy (RSC) augmented with AFL. METHODS: A retrospective review was conducted of patients who underwent RSC with AFL between January 2015 and November 2017. Outcomes evaluated include recurrence of prolapse on physical examination, prolapse symptoms, urinary incontinence, patient satisfaction based on the Patient Global Impression of Improvement (PGI-I) and complications. RESULTS: Twelve patients were identified with a median age of 68 years (range, 46-77 years) at the time of RSC with AFL. Eleven patients had a history of prior sling and/or vaginal mesh. The median operative time was 225 min (177-302 min). There were no intra- or postoperative complications. After a median follow-up of 14.7 months (5.7 to 39 months), the median PGI-I response was 2 (range, 1-3, very much to a little better). No recurrent or persistent apical prolapse was observed. Three patients (25%) reported recurrence of sensation of a vaginal bulge, which were all due to anterior vaginal wall prolapse. CONCLUSIONS: RSC can be performed with AFL and should be considered in patients with a history of mesh complications. Overall patient satisfaction was high. While these short-term outcomes are encouraging, further studies are needed to assess long-term durability of anatomic results.

Lack of uniformity among United States recommendations for diagnosis and management of acute, uncomplicated cystitis.

INTRODUCTION AND HYPOTHESIS: Acute, uncomplicated cystitis is one of the most common bacterial infections seen in clinical practice. Quality improvement and antibiotic stewardship efforts to optimize cystitis management rely on clinicians managing patients in a manner recommended by experts and guidelines. However, it is unclear if recent recommendations for cystitis from experts and guidelines from US medical societies that provide recommendations are well aligned. METHODS: We examined recommendations and guidelines for acute, symptomatic cystitis in women published in US medical societies' journals from January 1, 2008, to December 31, 2016, within the fields of family medicine, obstetrics and gynecology, internal medicine, female pelvic medicine and reconstructive surgery, and infectious diseases. RESULTS: All recommendations endorsed the use of symptoms and urine dipstick to diagnose cystitis. Some societies did not recommend urine dipstick in patients with recurrent urinary tract infection (UTI), classic UTI symptoms, or a lack of underlying conditions or competing diagnoses. All endorsed nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin as first-line agents. Some guidelines classified fluoroquinolones as second- or third-line, while others considered them first-line treatment for UTI. Avoiding use of amoxicillin and ampicillin, antibiotic agents with high prevalence of resistance in the US, was recommended by some societies. CONCLUSIONS: US recommendations differed in their approach to the treatment of acute, uncomplicated cystitis. Lack of uniformity likely contributes to clinical management variance for patients with UTI and hampers quality improvement and antibiotic stewardship efforts aimed at promoting optimal management. Our findings emphasize the need for more consistent recommendations for cystitis management.

Translabial Ultrasound in Midurethral Sling (Mesh) Visualization and Erosion Detection in Women With Stress Urinary Incontinence: A Retrospective Pilot Study.

Sling erosion is a significant complication of midurethral sling (mesh) placement for stress urinary incontinence, a common pelvic floor disorder. The goal of this retrospective case-control pilot study was to evaluate the performance of translabial ultrasound (TLUS) and magnetic resonance imaging in diagnosing mesh erosion. Therefore, women who underwent surgery in the setting of prior failed midurethral sling for stress urinary incontinence were identified from the hospital database. The case subcohort comprised all women with intraoperatively documented erosion, and the control subcohort comprised an equal number of randomly selected patients without erosion. The data consisted of selected clinical parameters, the presence of erosion at surgery (reference standard) and at cystourethroscopy, and dual-reader preoperative TLUS consensus interpretation for mesh location (intraluminal, mural, and extramural) and erosion (defined as intraluminal or mural mesh location). Odds ratios were calculated for the selected clinical parameters. Of the 198 women identified, 15 (8%) had mesh erosion at surgery into the lower urinary tract. The sensitivity, specificity, and accuracy of TLUS and cystourethroscopy in detecting erosion in the combined group of cases and controls (30 women) were 93%, 88%, and 90%, as well as 67%, 100%, and 83%, respectively (TLUS Cohen κ = 0.85). Thus, TLUS may be a good diagnostic tool in diagnosing mesh erosion. Only 7 of 30 women had pelvic magnetic resonance examination, and mesh fragments were not visualized. Case-control comparison of the selected clinical parameters was not statistically significant.

Translabial US: Preoperative Detection of Midurethral Sling Erosion in Stress Urinary Incontinence.

Purpose To evaluate the performance of translabial (TL) US in preoperative detection of sling erosion into pelvic organs with cystourethroscopic and surgical correlation. Materials and Methods The study cohort included women who underwent surgery at a subspecialty center (from 2008 to 2016) for suspected mesh complications in the setting of previous midurethral sling placement for stress urinary incontinence (from 1999 to 2012) with available preoperative TL US imaging. Clinical information, the finding of sling erosion identified intraoperatively and at cystourethroscopy, and blinded dual-reader radiologic analysis of the TL US studies for mesh location (intraluminal, mural, or extramural) relative to pelvic organs (bladder, urethra, vagina, or rectum) were evaluated. The diagnostic performance of TL US was correlated with the reference standard of surgical findings. The consensus of two radiologists was recorded, and interobserver agreement was evaluated with the κ statistic. Results Of the 124 women who were suspected of having sling erosion (mean age, 57.5 years ± 11.1 [standard deviation]), 15 women (12.1%) had sling erosion into the urethra or bladder at surgery. Sensitivity and specificity for erosion at TL US were 53% (95% confidence interval: 45%, 62%) and 100% (95% confidence interval: 97%, 100%), respectively, when erosion was defined as only intraluminal mesh products. Sensitivity and specificity for erosion at TL US were 93% (95% confidence interval: 89%, 98%) and 72% (95% confidence interval: 65%, 80%), respectively, when erosion was defined as visualizing either intraluminal or intramural mesh products. Interobserver agreement (κ value) was 0.95. Cystourethroscopy had 67% sensitivity and 100% specificity for sling erosion. Conclusion Preoperative translabial US can be used to detect sling erosion into the lower urinary tract, with sensitivity up to 93% and specificity up to 100%. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Benson and Phillips in this issue.

Female Caudal Duplication Syndrome: A Surgical Case Report With 10-Year Follow-up and Review of the Literature.

Caudal duplication syndrome is an exceedingly rare condition that manifests as duplicative anomalies of the gastrointestinal and genitourinary systems. We present a case of an adult patient born with multiple congenital anomalies including duplicated reproductive and urinary systems. She presented to our center for initial evaluation 11 years ago largely experiencing right-sided pelvic organ prolapse and bilateral urinary tract voiding dysfunction. She underwent successful surgical management and presented several years later for recurrent symptoms. We describe her presentation and our surgical experience, including complications and outcomes, for this case. We also review caudal duplication syndrome-its etiology, clinical presentation, diagnostic workup, surgical intervention (if any), and recommendations.

Public Awareness of Uterine Power Morcellation Through US Food and Drug Administration Communications: Analysis of Google Trends Search Term Patterns.

BACKGROUND: Uterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation. OBJECTIVE: We aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication. METHODS: Weekly relative search volume (RSV) was obtained from Google Trends using the term "morcellation." Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term "morcellation" over this time. RESULTS: The mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P<.001). The mean number of webpages containing the term "morcellation" in 2011 was 10,800, rising to 18,800 during 2014 and 36,200 in 2017. CONCLUSIONS: Google search activity about morcellation of uterine specimens increased significantly after the FDA communications. This trend indicates an increased public awareness regarding morcellation and its complications. More extensive preoperative counseling and alteration of surgical technique and clinician practice may be necessary.

Clinical predictors and risk factors for vaginal mesh extrusion.

PURPOSES: Our study aims to enhance the accuracy of the clinical diagnosis in patients with vaginal mesh extrusion following transvaginal mesh placement for pelvic organ prolapse using significant clinical parameters and risk factors. METHODS: All patients who underwent vaginal mesh removal were retrospectively reviewed from January 2000 to May 2014. Eligible patients were divided into two groups according to the presence of vaginal mesh extrusion. RESULTS: A total of 862 patients, 798 were included. 357 (44.7%) had evidence of vaginal mesh extrusion, and 441 (55.3%) had no evidence of vaginal mesh extrusion. The mean age of the vaginal mesh extrusion group was slightly higher than in the group without vaginal mesh extrusion (58.7 ± 11.2 vs. 56.4 ± 11.5, respectively; p = 0.002). From multivariate analysis, the significant clinical correlations for vaginal mesh extrusion were vaginal bleeding [60 (16.9) vs. 14 (3.2%), p < 0.001], hispareunia [48 (13.5) vs. 15 (3.4%), OR = 4.163, p < 0.001], and vaginal discharge [45 (12.6) vs. 18 (4.1%), p = 0.001]. The risk factors were multiple mesh implantations [218 (67.06) vs. 175 (39.68%), p < 0.001] and menopause [314 (88) vs. 364 (82.7%), p = 0.145]. Demographic data, including BMI, sexual activity, vaginal atrophy, both local and systemic hormonal use, smoking status, and hysterectomy status, were not significantly different, as well as the clinical symptoms including dyspareunia, vaginal infection, and symptomatic vaginal bulge. CONCLUSIONS: Vaginal bleeding, hispareunia, and vaginal discharge were the most significant clinical predictors for raising suspicion of vaginal mesh extrusion. Multiple mesh implantations were a significant risk factor for extrusion.

Suprameatal urethrolysis with Martius flap for refractory bladder outflow obstruction following stress incontinence surgery in females.

AIMS: To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO). METHODS: A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence. RESULTS: Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P < 0.01). Among the seven patients who required catheterization preoperatively, five patients (71%) recovered volitional voiding. Two patients (18%) continued to require indwelling or intermittent catheterization and underwent additional surgery for BOO. SUI recurred in one patient (9%). UUI persisted in all four patients who reported this preoperatively. CONCLUSIONS: SMUM is successful in improving or relieving refractory BOO in this challenging patient population. After TVU, we believe that Martius flap interposition is critical to preventing recurrent fixation of the urethra to the pubic bones and thus achieving improved voiding.

The Risk of Recurrent Urinary Incontinence Requiring Surgery After Suburethral Sling Removal for Mesh Complications.

OBJECTIVE: We sought to examine the risk of recurrent stress urinary incontinence (SUI) after suburethral sling mesh removal or excision. MATERIALS AND METHODS: We conducted a retrospective cohort study of patients who were continent before removal or excision of synthetic midurethral slings; this cohort of 278 subjects was much larger than seen in previous such studies. Patients with preoperative incontinence, additional vaginal mesh placements, prior mesh revision/excision, existing SUI, and prior pelvic radiation or fistula were excluded. Only patients with follow-up detailing continence status within 1 year of mesh removal were examined. RESULTS: Of 278 patients, 117 (70 retropubic and 47 transobturator) midurethral sling removals met inclusion criteria. Demographic data were comparable between groups. Presenting symptoms were also similar, with similar extrusion rates. Chronic pain was the reason for mesh removal in 80% of cases. In 1 year of follow-up, 38.6% (27/70) retropubic and 34.0% (16/47) transobturator sling removals had SUI requiring an anti-incontinence procedure. Total sling mesh removal was performed in 51.4% of retropubic vaginal mesh and 51.1% of transobturator mesh cases. CONCLUSION: In this continent population with sling complications, approximately 1/3 developed significant SUI within 1 year of mesh removal requiring anti-incontinence surgery, regardless of the amount or type of mesh removed. Total mesh removal did not increase SUI risk.

Complete Excision of Sacrocolpopexy Mesh With Autologous Fascia Sacrocolpopexy.

OBJECTIVE: To evaluate the safety and short-term efficacy of complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy. METHODS: A retrospective cohort study of patients undergoing complete sacrocolpopexy mesh excision and concomitant autologous fascia sacrocolpopexy from March 2013 to September 2016 was conducted. The primary objective was assessment of perioperative outcomes including complications within 60 days of surgery. The secondary outcome measure was surgical success defined as no need for retreatment by either surgery for apical prolapse or pessary. RESULTS: Nineteen patients were identified. Median patient age was 56 years old (range 35-78). Median time from mesh placement to surgical excision was 4.5 years (0-13). Indications for mesh excision included refractory pelvic pain in 18 patients (95%), symptomatic mesh exposure in 8 patients (42%), and bilateral ureteral obstruction with ureterovaginal fistula in 1 patient (5%). Median operative time, estimated blood loss, and length of hospital stay were 228 minutes (133-362), 200 mL (50-1000), and 5 days (2-9), respectively. The rate of minor and major complications within 60 days was 36.8% and 5.3%, respectively. There were no cases of bladder or bowel injury. At a median follow-up of 9.9 months (2.4-39) no patient required secondary surgery for apical vaginal prolapse or retreatment with pessary. CONCLUSION: Complete sacrocolpopexy mesh excision with concomitant autologous fascia sacrocolpopexy can be accomplished safely with a low rate of major complications. These are short-term findings and longer follow-up of anatomic and functional outcomes is needed.

Comparison of Times to Ureteral Efflux after Administration of Sodium Fluorescein and Phenazopyridine.

PURPOSE: There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated the time to excretion of phenazopyridine vs a newly identified alternative, sodium fluorescein. MATERIALS AND METHODS: We analyzed prospectively collected data on a cohort of women who underwent pelvic reconstructive surgery in 2015. Per provider preference patterns a number of patients were administered 200 mg phenazopyridine orally with a sip of water 1 hour prior to the start of operative time. Other patients were given 0.5 ml 10% sodium fluorescein intravenously in the operating room. In all cases time was measured between the administration of the agent and the visualization of color changes consistent with agent efflux in an indwelling catheter, which was placed at the start of the operation. Differences in excretion times between the groups were compared with the Wilcoxon rank sum test. RESULTS: Seven women received phenazopyridine and 5 received sodium fluorescein. Mean excretion time was significantly longer in the phenazopyridine group compared to the sodium fluorescein group (81.9 vs 5.1 minutes, p = 0.0057). Median excretion time for phenazopyridine was 70 minutes (range 59 to 127) and for sodium fluorescein it was 5 minutes (range 3 to 9). CONCLUSIONS: Sodium fluorescein is excreted significantly faster in the operating room compared to phenazopyridine. Depending on the cost of these agents at an institution, in addition to the desire to decrease operative time, this may impact practice patterns and agent selection.

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

OBJECTIVES: Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). METHODS: Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. RESULTS: One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. CONCLUSIONS: In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

Symptom Improvement After Prolapse and Incontinence Graft Removal in a Case Series of 306 Patients.

OBJECTIVES: We report our experience with removal of synthetic and biologic implants used in pelvic reconstruction in a tertiary referral center from 2005 to 2012. METHODS: We performed a retrospective cohort study of all consecutive patients who underwent surgical implant removal for treatment of implant-related complications. Symptoms were determined by patient self-assessment including validated questionnaires. One hundred seventy-nine patients completed follow-up. RESULTS: Three hundred six patients underwent removal for exposure or erosion (57%), pain (46%), and urinary symptoms or incontinence (54%). Ninety patients (29%) had previous revision. Eleven percent had pelvic organ prolapse (POP) implants, 48% had sling implants, and 41% had both implants. Mean time from removal to follow-up was 2 years (median, 2 years; range, <1-7).The majority of patients experienced symptom improvement after implant removal. Seventy-eight percent of those with pain reported pain improvement, 9% reported no change, and 14% experienced worsening. Symptom improvement was reported by 79% of those who underwent removal of a POP implant alone, 79% of those who underwent removal of POP and sling implants, and 83% of those who underwent removal of a sling alone. Quality of life was significantly improved after implant removal overall (P < 0.05) for those who underwent removal of POP and slings, and slings alone, but not for those with POP removal only. CONCLUSIONS: Pain is among the most common symptoms reported in women referred to our institution for implant-related complications. In a series of 306 complex patients with a range of implants and symptoms, removal improved implant-related pain in the majority of patients.

Long-term symptom improvement and overall satisfaction after prolapse and incontinence graft removal.

OBJECTIVES: We report long-term symptom improvements and overall satisfaction in patients after removal of grafts used in pelvic reconstruction in a tertiary referral center. METHODS: We analyzed patients who underwent graft removal for treatment of related complications and who were followed for at least 2 years. Symptoms were determined by patient self-assessment questionnaires. RESULTS: Seventy-nine patients underwent partial or complete graft removal from 2005 to 2011 and met inclusion criteria. The mean follow-up time was 4.0 years (median, 3.4 years; range, 2.0-7.6 years). Forty-seven percent (37 patients) had implants for both prolapse and incontinence, 40% (32 patients) had incontinence implants only, and 13% (10 patients) had prolapse implants only. Thirty percent of those with both implants presented with multiple symptoms compared to 50% of those with prolapse implants and 44% of those with incontinence implants only. At follow-up, 75% (56 patients) reported that their symptoms were better and 15% (11 patients) reported that their symptoms were worse. Of patients who underwent graft removal for pain alone, 74% (17 patients) improved whereas17% (4 patients) were worse. When asked about spending the rest of their lives with their current symptoms, 49% (38 patients) reported positively whereas 44% (34 patients) reported negatively. Forty-one patients underwent one or more additional treatments. CONCLUSIONS: Graft-related complications are often treated with surgical excision. In a cohort of 79 patients in whom implants were removed an average of 4 years earlier, 75% still report symptom improvement and 49% report good quality of life. However, many patients still feel dissatisfied and sought additional treatment during long-term follow-up. These data can be used to counsel patients considering removal of pelvic reconstruction grafts.