Novel technique of laparoscopic mid-urethral autologous rectus fascial sling for stress urinary incontinence.

Serious concerns have been raised over the safety of vaginal mesh tapes for stress urinary incontinence (SUI). Autologous rectus fascial sling and the more recent 'sling on a string' through a laparotomy are gaining popularity as native tissue options for SUI. We describe a novel technique of laparoscopic mid-urethral autologous rectus fascial sling for SUI. Ten patients underwent this new technique safely. At 12 months, all patients reported cure of SUI with normal voiding. The advantages of this technique include the minimal access approach, introduction of the sutures under laparoscopic guidance, and avoidance of over-tightening of the sling.

Long-Term Mesh Exposure 5 Years Following Minimally Invasive Total Hysterectomy and Sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy. METHODS: In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes. RESULTS: Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types. CONCLUSION: The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.

Clinical outcomes after total excision of transobturator tape inserted for treatment of stress urinary incontinence.

INTRODUCTION: Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). There is a paucity in evidence about the outcomes of TETOT, which is a complex operation. This study aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh center. METHODS: All women between 2017 and 2022 who underwent TETOT in one mesh center were reviewed. Background demographics and preoperative symptoms were recorded retrospectively. Outcome data were collected using patient global impression of improvement (PGI-I) scales via telephone review and analyzed using SPSS 25. RESULTS: Forty-five women underwent telephone review in May 2022, on average 27.9 months (range: 3-60) after TETOT. Mean age was 55 and body mass index (BMI): 30; 82% were postmenopausal, 20% were smokers, and 73.3% had recurrent SUI before excision. Indications for excision were infection (4%), vaginal exposure (24%), urethral perforation (9%), and chronic pain not associated with other complications (60%). Two women with recurrent SUI opted for a concomitant fascial sling; both reported a PGI of "very much improved" regarding SUI postoperatively. Only 12 women (26.5%) did not have SUI before excision; of these 9 (75%) reported new SUI postoperatively. Pain improved for 57.8%, but worsened for 24.4%. Although not statistically significant (p = 0.055), more women who underwent TETOT for pain alone reported worsening pain than those with pain with an additional complication (37% vs. 5.55%). Overall, 62.2% women felt "better" after their excision, 17.8% felt "worse." DISCUSSION: After TETOT, 62% of women felt better. Improvement in pain was reported by 58%-those with chronic pain without another complication reported improvement in pain less frequently (48% vs. 72%) and worsening pain more frequently (37% vs. 6%). Existing SUI worsened in 65% of women and 75% developed new SUI. There appears to be discordance between reporting global improvement with worsening of commonly measured clinical outcomes. CONCLUSION: Outcome data are important for counseling women about the risks and benefits of TETOT. Women and clinicians may have different attitudes to the possible benefits of TETOT, as evidenced by women reporting feeling better despite continuing pain or SUI. Conventional outcome measures do not adequately capture all outcomes that are important to patients.

Ten-year outcomes following ventral hernia repair: making the case for better post-market surveillance in the USA.

BACKGROUND: We sought to identify the 10-year complication and recurrence rates and associated sociodemographic and operative characteristics associated with non-mesh versus mesh-based ventral hernia repairs (VHRs). METHODS: This was an IRB-approved (2020H0317) retrospective longitudinal study of patients undergoing mesh or non-mesh VHR from 2009-2019 at a single tertiary-care institution. The electronic medical record was used to collect sociodemographic, clinical, and intraoperative details, and early (≤ 30 days) and long-term (> 30-day) postoperative complications. Up to ten-year follow-up was obtained for long-term complications, categorized as: hernia recurrence reoperation (HRR), major complications requiring emergency surgery (MCES) (defined as non-elective operations related to the abdominal wall), and non-recurrence procedural intervention (NRPI) (defined as any procedures related to the abdominal wall, bowel, or mesh). Kaplan-Meier survival curves were obtained for each long-term complication. RESULTS: Of the 645 patients identified, the mean age at index operation was 52.51 ± 13.57 years with 50.70% female. Of the index operations, 21.24% were for a recurrence. Procedure categories included: 57.36% incisional, 37.21% non-incisional umbilical, 8.22% non-incisional epigastric, 3.88% parastomal, 0.93% diastasis recti, and 0.47% Spigelian hernias. Operative approaches included open (n = 383), laparoscopic (n = 267), and robotic (n = 21). Fascial closure (81.55%) and mesh use (66.2%) were performed in the majority of cases. Median follow-up time was 2098 days (interquartile range 1320-2806). The rate of short-term complications was 4.81% for surgical site infections, 15.04% for surgical site occurrences, and 13.64% for other complications. At 10 years, the HRR-free survival probability was 85.26%, MCES-free survival probability was 94.44%, and NRPI-free survival probability was 78.11%. CONCLUSIONS: A high proportion of patients experienced long-term recurrence and complications requiring intervention after index VHR. For many patients, a ventral hernia develops into a chronic medical condition. Improved efforts at post-market surveillance of operative approaches and mesh location and type should be undertaken to help optimize outcomes.

Total trans-obturator tape (TOT) removal; a case series including pain and urinary continence outcomes.

INTRODUCTION AND HYPOTHESIS: For many years, mid-urethral mesh tape (MUT) was the gold-standard procedure for management of stress urinary incontinence (SUI). However, significant concerns were raised over its safety. We present a case series of total trans-obturator tape (TOT) removals, performed in a tertiary unit over a 3-year period. We aim to evaluate improvement of pain and change in urinary continence symptoms following mesh explantation. METHODS: This is a retrospective case series of the outcomes of total TOT removal. Primary outcome is the change in pain scores following total removal, assessed preoperatively, at discharge and follow-up. Secondary outcomes were perioperative complications, including return to theatre, re-admission rates and incidence of worsening SUI and overactive bladder symptoms (OAB) postoperatively. Statistical analyses were performed using SPSS 27.0 package (IBM, Chicago, IL) and the GraphPad Prism 9 statistical packages. RESULTS: Nineteen women were identified. Mean age was 52 years and mean BMI was 31. Indications for mesh removal were: chronic pain (95%), vaginal exposure (37%) and pelvic sepsis (5%). No patients had return to theatre. Median intraoperative blood loss was 200 ml (interquartile range [IQR]: 150-288). Mean length of mesh excised was 22 cm. Mean postoperative hospital stay was 2 days. At follow-up, most patients (72%) reported "improvement" of their mesh-related pain at follow-up, while 6% reported "worsening" of pain. Eighty-three per cent of patients reported worsening SUI, and 50% reported worsening OAB symptoms. CONCLUSIONS: In the absence of sepsis, significant intraoperative complications are rare during total TOT removals. While 72% of patients reported improvement of their mesh-related pain, 6% still reported worsening pain after total mesh excision.

Acceptability and effectiveness of a multidisciplinary team approach involving counselling for mesh-removal patients.

Patients with complications following mesh removal risk a variety of symptoms, and can view medical intervention negatively. This study explored the patient-acceptability of a Multidisciplinary Team (MDT), and whether the presence of a Counsellor would be accepted and effective. Twenty consecutively referred women, who had undergone mesh-removal but experienced complications were interviewed about their experiences, and completed the Queensland scale for pelvic floor symptoms, McGill Pain Questionnaire, and Hospital Anxiety and Depression Scales, before and after treatment. Patients had high levels of pelvic-floor symptoms, sensory and affective pain, anxiety, and depression. 70% reported a positive MDT experience; predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which commenced within one week of referral, typically lasted 1-4 sessions, and reduced pelvic-floor symptoms, affective pain, anxiety, and depression. Results suggest that the MDT approach is generally acceptable for this patient group, and that mesh-removal patients accept and benefit from input by a Counsellor.Impact statementWhat is already known on this subject? Concerns have been raised regarding the safety of mesh insertion. Multidisciplinary Teams (MDTs) are suggested to offer a strong approach to managing many women's health conditions, but no studies have examined mesh-removal patients, making generalisation difficult to the current patient group. Furthermore, it is unknown whether an MDT approach, including a Counsellor, would be acceptable to mesh-removal patients.What do the results of this study add? Patients had high levels of pelvic-floor symptoms, pain, anxiety, and depression. 70% reported the MDT experience as positive, predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which reduced pelvic-floor symptoms, affective pain, anxiety, and depression.What are the implications of these findings for clinical practice and/or further research? The Counselling provided as part of the MDT approach was able to commence quickly, did not require many sessions, and reduced reported pelvic-floor symptoms, affective pain, anxiety, and depression. These findings suggest that an MDT approach involving Counselling is generally acceptable, and that mesh-removal patients accept and benefit from the input of a Counsellor, as part of their treatment.

[Autologous fascia pubovaginal slings in women with stress urinary incontinence at high risk of mesh/device-related complications]. / Bandelette aponévrotique pubovaginale pour incontinence urinaire d'effort chez les femmes à risque de complications prothétiques.

INTRODUCTION: Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population. MATERIAL AND METHODS: The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months. RESULTS: Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). CONCLUSION: The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes. LEVEL OF PROOF: 4.

Clinical analysis of pain after transvaginal mesh surgery in patients with pelvic organ prolapse.

BACKGROUND: The purpose of this study was to investigate the relevant factors of pain after transvaginal mesh (TVM) surgery for the treatment of pelvic organ prolapse and to analyse the management and relief of the pain. METHODS: A multicentre retrospective study of a clinical database of patients who underwent TVM surgery was conducted, and pain related aspects were analysed. RESULTS: A total of 1855 patients were included in the study. We divided the patients into two groups: pain-free (1805 patients) and pain (50 patients) group. The incidence of pain after TVM surgery was 2.70%, with a median occurrence time of 7.5 months. Pain mainly involved the vagina, perineum, buttocks, groin, inner thighs, and lower abdomen. Excessive intraoperative blood loss (OR = 1.284, 95% CI 0.868-2.401) and postoperative anatomic failure (OR = 1.577, 95% CI 0.952-3.104) were analysed as risk factors with statistical significance. Mesh exposure rate in the pain group was 38%, showing a significant difference between the groups (P < 0.01). Forty patients underwent non-surgical treatment, with a relief rate of 40.0%, 33 patients received surgical treatment, 15 underwent partial mesh removal, and 18 underwent complete mesh removal, with a relief rate of 84.8%. The total relief rate was 88% within all 50 patients suffering from pain. CONCLUSIONS: Excessive intraoperative bleeding and unsatisfactory postoperative anatomic outcomes can increase the risk of postoperative pain; mesh exposure is also associated with the pain. Most patients can get pain relief with proper management, more than half of whom may need mesh removal with differing approach.

User testing a patient information resource about potential complications of vaginally inserted synthetic mesh.

BACKGROUND: Vaginal mesh implants are medical devices used in a number of operations to treat stress urinary incontinence and pelvic organ prolapse. Although many of these operations have delivered good outcomes, some women have experienced serious complications that have profoundly affected their quality of life. To ensure that evolving patient information is up-to-date, accurate and appropriate, the Transvaginal Mesh Oversight Group 'user-tested' a newly developed Scottish patient resource, the first to focus exclusively on the issue of complications. The aim of this research was to gather feedback on usability, content, language and presentation to inform the development of the resource from a user perspective. METHODS: The experience of using the patient resource was captured through semi-structured interviews that followed a 'think-aloud' protocol. The interviewer observed each participant as they went through the resource, asking questions and making field notes. Participants' comments were then categorised using a validated model of user experience and subsequently analysed thematically. RESULTS: Thirteen people participated in the user testing interviews, including women with lived experience of mesh implants (n = 7), a convenience sample of staff working for Healthcare Improvement Scotland (n = 5) and a patient's carer (n = 1). The majority of participants considered the resource as clear and helpful. Respondents reported that some presentational aspects promoted usability and understandability, including the use of a font that is easy to read, bullet lists, coloured headings and simple language. Barriers included the reliance on some technical language and an explicit anatomical diagram. Participants endorsed the valuable role of health professionals as co-mediators of patient information. CONCLUSIONS: The findings illustrate the value of undertaking in-depth user-testing for patient information resources before their dissemination. The study highlighted how the direct guidance or navigation of a patient information resource by a health professional could increase its salience and accuracy of interpretation by patients, their families and carers. These insights may also be useful to other developers in improving patient information.

Mid-urethral sling revision for mesh exposure-long-term outcomes of two surgical techniques from a comparative clinical retrospective cohort study.

OBJECTIVE: To compare vaginal closure with versus without sling excision in the management of vaginal sling exposure following mid-urethral sling (MUS). DESIGN: Clinical retrospective cohort study. SETTING: Tertiary urogynaecological centre in Australia. POPULATION: Women with urodynamic stress urinary incontinence (SUI) who had a MUS (n = 2823) during 1999-2017 with a follow-up period up to December 2018. Thirty-three women (1%) had sling exposure and 31 required surgical intervention (1%). METHODS: Clinical review with analysis of surgical database and patient records. MAIN OUTCOME MEASURES: The primary outcome was successful closure and resolution of exposure-related symptoms without the need for re-surgery. Secondary outcomes were repeat procedure and recurrent incontinence following revision. RESULTS: Mean follow up was 103 months. Of the 20 women with a primary excision and closure approach, 19 had successful closure. Seven of 11 women with simple vaginal closure without excision needed another surgery for recurrent mesh exposure. Recurrence of stress incontinence did not occur in any of the four who had 'successful' closure without excision. Of those who had sling division/removal without a concomitant stress continence procedure, 32% (7/22) required further surgery. CONCLUSION: Sling excision and repair have better outcomes with less recurrence of sling exposure compared with simple closure. Following sling removal, one of three women will develop SUI recurrence and require surgery. TWEETABLE ABSTRACT: #Slingexcision &repair leads to less recurrence of exposure versus #simpleclosure for #slingmeshexposure.

Joint position statement on the management of mesh-related complications for the FPMRS specialist.

The scientific approach to categorizing mesh complications and optimal methods to address them have been complicated by the rapid proliferation and evolution of materials and techniques that have been used over the past 20 years in surgical treatment of pelvic floor disorders. In addition, terminology used to diagnose and categorize mesh complications and the descriptions of surgical procedures to manage them have been adopted inconsistently, further hampering the development of a collective experience with a standardized lexicon. Finally, much of the high-quality data on management of mesh complications is based on materials that are rarely used or not commercially available today.Women experiencing mesh complications need to be heard and should have access to resources and providers who are most able to help. Many women require multiple procedures to address their mesh complications, and for some of these patients, relief is incomplete. We should strive to optimize the treatment at the initial diagnosis of a mesh-related complication.This Position Statement has 4 goals:1. Using the best and most relevant evidence available, provide guidance for the FPMRS subspecialist caring for patients who may be experiencing mesh complications2: Provide an algorithm outlining treatment choices for patients with mesh-related complications that can be used as a platform for shared decision making in the treatment of these complications3: Identify and prioritize gaps in evidence concerning specific mesh complications and their treatments4: Identify provider and health facility characteristics that may optimize the outcomes of treatments for these complications.

MR scan evaluation of pelvic organ prolapse mesh complications and agreement with intra-operative findings.

INTRODUCTION: An increasing number of women are presenting with symptoms after the placement of mesh implants for prolapse which may be attributable to a mesh implant complication. MRI imaging can be used to evaluate abdominally placed mesh but there is no published research evaluating the use of MRI in this group of women. The objective of our study was to report our experience as a tertiary centre in evaluating abdominal mesh with MR imaging and the agreement of MR reports with surgical findings. STUDY DESIGN: A retrospective observational cohort study (Canadian Task Force classification II-2) of all women referred to our tertiary unit who underwent an MR scan for investigation of symptoms of mesh complication following an abdominally placed mesh implant between June 2006 and September 2018 was performed. The reports of MR images were compared with the findings at surgery. RESULTS: MR scan was performed in 87 with suspected mesh complications. MR scan detected mesh failure in 42.1% of women (37/87), infection in 12.6% (11/87), compression in 2.3% (2/87), exposure in 12.6% (11/88), bowel extrusion in 2.3% (2/87) and inflammation in 11.5% (10/87). Agreement between MR scan report and surgical diagnosis was almost perfect for mesh failure, infection and compression, whilst agreement was only moderate for mesh erosion and signs of inflammation (failure κ = 0.97, infection κ = 0.94, compression κ = 1.0, exposure κ = 0.58 and inflammation κ = 0.24). CONCLUSION: These data provide information on the role of MR imaging in the investigation of women presenting with suspected intra-abdominal POP mesh complications including recurrence.

Social media awareness among non-urogynecologists regarding the current mesh discussions in urogynecology: a survey study.

INTRODUCTION AND HYPOTHESIS: There has been a great deal of discussion about mesh complications in urogynecology in recent years. However, awareness of other doctors who are not urogynecologists is unknown. This study was aimed at determining the level of awareness of mesh discussions among medical doctors whose specialty is not urology or gynecology. METHODS: A survey study was administered, and all medical doctors, except gynecologists and urologists, were invited. Respondent doctors were classified into four groups: King's College Hospital (KCH), UK; Uludag University Hospital (UUH), Turkey; the United States (USA); and the world (WORLD). The primary outcome was the awareness of mesh discussion in urogynecology, and the secondary outcome was the social media awareness of the mesh discussion. RESULTS: 1231 doctors responded to the survey. The awareness of the current mesh problems among the respondent doctors was 15.8% in KCH, 15.4% in UUH, 26.9% in the USA, and 16.2% in WORLD. The social media awareness about mesh problems was 20.8% in KCH, 20.3% in UUH, 32.8% in the USA, and 20.6% in WORLD. Although there were no differences among three of the groups with regard to primary and secondary outcomes, the USA group score was statistically significantly higher than the others. CONCLUSIONS: Social media can influence doctors' thinking on controversial academic issues. In this survey study, non-urogynecologist doctors in the USA cohort have higher awareness levels and a higher social media awareness level than other groups.

Laparoscopic complete sacrocolpopexy mesh removal for right-sided gluteal pain and recurrent mesh erosion.

AIM OF VIDEO: The aim was to demonstrate laparoscopic complete excision of sacrocolpopexy mesh from a 65-year-old woman who had presented with delayed onset of persistent right-sided gluteal pain. METHOD: The patient was referred to our unit, having undergone a laparoscopic sacrocolpopexy for vault prolapse 7 years earlier, with a type 1 polypropylene mesh. Four years after the primary surgery, she first noticed symptoms of spontaneous vaginal pain together with deep dyspareunia, and right-sided gluteal pain. Clinical examination revealed mesh erosion at the vaginal vault. This was managed at her local hospital, with excision of the small exposed portion of the mesh and over sewing, from a vaginal approach. She continued to be symptomatic following this procedure. When her symptoms still failed to improve 3 years later, a tertiary referral was made to our unit. At laparoscopy, minimal adhesions between the bowel and the mesh were noted and divided. After carefully dissecting the right ureter and reflecting the bladder, the entire sacrocolpopexy mesh was removed with its ProTack fasteners. The entire specimen was retrieved in one piece through the open vault and the vagina was sutured with 2.0

The experiences of seven women living with pelvic surgical mesh complications.

INTRODUCTION: This research sought to address a gap in the literature about women's lived experience of pelvic surgical mesh complications, conducted by an insider researcher. An increasing number of women who have pelvic mesh surgeries with a view to improving their lives are experiencing life-altering complications. Without knowledge of these experiences we cannot know how best to care for affected women and prevent harm to further women. METHODS: Van Manen's hermeneutic phenomenological method was used. Seven women with pelvic mesh complications aged 43-69 years were enrolled using criterion sampling. Four of the seven women had surgical mesh for both pelvic organ prolapse (POP) and stress urinary incontinence (SUI), one for POP only, and two for SUI only. The women completed a modified ICIQ-LUTSqol questionnaire pre-interview and answered a separate global spiritual question adapted from the HOPE tool, a framework for spiritual assessment. Women were interviewed once using a semi-structured approach. Data were analysed using Van Manen's selective reading technique and organized according to Lifeworld Existentials. RESULTS: Modified ICIQ-LUTSqol scores ranged between 43 and 76 (range 19-76), with a mean of 62.2 (SD + 10.011) demonstrating significant impact on quality of life. Themes emerging from the analysis were: (1) lived space: 1(a) feeling powerless in the medical space, 1(b) living in a shrinking world; (2) lived body: 2(a) living with unrelenting pain, 2(b) inhabiting a body that can no longer be relied on; (3) lived time: 3(a) living in the gap between what was and what could have been; (4) lived other: 4(a) suffering in silence, 4(b) finding absolute Other and others as a source of strength. CONCLUSIONS: Pelvic surgical mesh complications have an extensive adverse impact on the lifeworld of women experiencing complications. Failure to acknowledge mesh complications as treatment injury stalls the development of safer alternatives and changes needed to industry practices, regulation, clinical practice, and monitoring to keep women undergoing innovative urogynaecological procedures safe.

Predictors of sling revision after mid-urethral sling procedures: a case-control study.

OBJECTIVE: To identify patient characteristics and surgical factors predictive of complications requiring mid-urethral sling (MUS) revision/removal. DESIGN: Case-control study. SETTING: Tertiary academic centre in Canada. POPULATION: One hundred and seven women undergoing MUS revision/removal between 2005 and 2016 were matched with 214 controls by date of index MUS procedure (2:1 ratio). METHODS: Data on patient and surgical factors were obtained via manual electronic and paper chart review. Three sets of pre-specified simple and multivariable logistic regression models were fitted to: (1) examine previously reported risk factors for MUS revision after primary surgical treatment; (2) identify preoperative predictors of MUS complications requiring revision/removal; and (3) identify surgical factors associated with this outcome after adjusting for potential confounding factors. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) for patient and surgical factors. RESULTS: The median time to MUS revision was 153 days (interquartile range, IQR 49-432 days). Active smoking status (OR 2.29, 95% CI 1.13-4.63, P = 0.03), having had a previous hysterectomy (OR 3.88, 95% CI 2.02-7.46, P < 0.01), and undergoing concomitant pelvic organ prolapse surgery at the time of the index MUS procedure (OR 2.63, 95% CI 1.32-5.52, P < 0.01) were independently associated with the need for MUS revision/removal. Sling type (obturator versus retropubic), method of tensioning (to cough versus over instrument), anaesthetic type, and estimated blood loss were not associated with this outcome in the analysis presented here. CONCLUSIONS: Active smoking status, having had a previous hysterectomy, and undergoing concomitant surgery for pelvic organ prolapse are risk factors for requiring subsequent MUS revision/removal. TWEETABLE ABSTRACT: Risk factors for sling revision include smoking, previous hysterectomy, and concomitant prolapse surgery.

Pelvic floor ultrasound in the diagnosis of sling complications.

PURPOSE: The mid-urethral synthetic sling (MUS) procedure has become the standard of care for treatment of female stress urinary incontinence. However, a small number of patients will have complications following MUS including failure, obstructive voiding, sling erosion, or chronic pain. This paper discusses the role of 2D and 3D ultrasound imaging in the evaluation of the female patient with complications following placement of a synthetic mid-urethral sling. RESULTS: The MUS is easily visualized as an echogenic structure on ultrasound and can be imaged by transperineal, transvaginal and introital approaches. Ultrasound allows dynamic assessment of the sling and can assist in the diagnosis of sling failure, obstruction, erosion and mesh related pain. CONCLUSIONS: Pelvic floor ultrasound has an emerging role in the assessment of complications following MUS surgery. 3D ultrasound can assist the clinician in assessment of the complex patient with multiple slings or meshes in situ.

Foundation for an evidence-informed algorithm for treating pelvic floor mesh complications: a review.

To address evidence gaps on the management of complications related to mesh in pelvic floor surgery, we created an evidence-based algorithm that includes defining evidence gaps. We utilized the Delphi method within a panel of surgeons treating mesh complications to define a treatment strategy. The first round provided a list of clinically based postulates that informed a review expanding postulates to recommendations and included grading of the quality of evidence. A second round informed the final algorithm. While the quality of the available evidence is low, it provides a framework for planning diagnosis and management of mesh-related complications. TWEETABLE ABSTRACT: Removal of mesh must balance resolution of complications with the risk of removal and recurrence of pelvic floor symptoms.

Mesh complications and failure rates after transvaginal mesh repair compared with abdominal or laparoscopic sacrocolpopexy and to native tissue repair in treating apical prolapse.

OBJECTIVE: Our objective was to quantitate the extent of complications and failure rate for apical prolapse repair with transvaginal mesh (TVM) use versus sacrocolpopexy over a minimum of 2 years of follow-up. METHODS: Truven CCAE and Medicare Supplemental databases 2008-2013 were used for analysis. Patients with apical prolapse repair via transvaginal mesh (TVMR), abdominal sacrocolpopexy (ASCP), laparoscopic sacrocolpopexy (LSCP), or native tissue repair (NTR) and continuously enrolled for years were in the study cohort. Surgical failures were identified by reoperation for any prolapse or subsequent use of pessary. SAS® 9.3 was used for analysis. RESULTS: Mesh removal/revision was reported highest in TVMR (5.1 %), followed by LSCP (1.7 %) and ASCP (1.2 %). In those with concomitant sling, combined rates for mesh/sling revision were high, at 9.0 % in TVMR + sling, 5.6 % in ASCP + sling, and 4.5 % LSCP + sling. Sling-alone cases reported a 3.5 % revision rate. Pelvic pain (16.4-22.7 %) and dyspareunia (5.6-7.5 %) were high in all three approaches for apical prolapse repairs. Reoperation for apical prolapse was more common for TVMR (2.9 %) compared with NTR (2.3 %) [odds ratio (OR) 1.27; confidence interval (CI) 1.1-1.47; p 0.002]. Both ASCP and LSCP were superior to NTR (ASCP 1.5 %, OR 0.63, CI 0.46-0.86; p 0.003) and LSCP 1.8 % (OR 0.79, CI 0.62-1.01; p 0.07). Overall prolapse recurrence, as indicated by any compartment surgery for prolapse and/or pessary use, was also noted highest in TVMR (5.9 % OR 1.23, CI 1.11-1.36; p <0.0001). Laparoscopic sacrocolpopexies were slightly superior at 4.0 % overall recurrence (OR 0.83, CI 0.7-0.98); p 0.03). Failure of incontinence surgery was higher when the initial procedure combined prolapse and sling surgery (1.97 %) versus sling alone (1.6 %). CONCLUSIONS: Reoperation for apical prolapse is more common with TVMR than with sacrocolpopexies and NTR. Incontinence procedures are more likely to fail when performed along with prolapse repair than when performed alone. When mesh is used for repair, mesh revision is highest with TVMR and lowest with ASCP.