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.

Polypropylene distal urethral sling for treatment of fenale stress urinary incontinence / Suporte uretral distal (sling) utilizando tela de polipropileno para o tratamento da incontinência urinária feminina de esforço

Introdução: Cirurgias para o tratamento da incontinência urinária de esforço utilizando a colocação de um "sling" têm sido realizadas com sucesso. Utilizando princípios cirúrgicos similares aos do "sling" com fascia de cadáver nós descrevemos a colocação de uma fina tela entrelaçada de polipropileno (Prolene) sob o terço médio-distal da uretra. Nós descrevemos nossa técnica e relatamos nossos resultados iniciais. Materiais e métodos: Um total de 263 pacientes tratadas consecutivamente foi avaliado. Todas apresentavam evidência clínica de incontinência urinária de esforço. As pacientes foram submetidas a uma avaliação pré-operatória que incluiu estudo video-urodinâmico, questionário de sintomas, e cistoscopia. Uma tela Prolene de 1 x 10 cm foi colocada sob o terço médio-distal da uretra. Num segmento mínimo de 1 ano (12-24 meses), as pacientes foram avaliadas por um questionário de sintomas urogenitais, exame físico, e medida do volume residual pós-micção. Resultados:Vinte e seis porcento das pacientes já haviam sido submetidas a cirurgias vaginais sem sucesso. Não foram observadas complicações graves tais como retenção permanente, erosão, infecção ou rejeição à tela. O tempo operatório médio foi de 27 minutos. Em 90 porcento das pacientes o cateter suprapúbico foi retirado em até 1 semana. Nenhuma paciente apresentou retenção permanente. Cento e vinte e oito pacientes tiveram seguimento de pelo menos 12 meses e foram incluídas na análise dos resultados. Destas pacientes, 96,4 porcento foram curadas ou melhoraram, e apenas 3 porcento desenvolveram urge-incontinência novamente. Comentários: é descrito um método novo, simples, rápido, barato e eficiente para corrigir a incontinência urinária de esforço, através da colocação de uma tela de Prolene sob a uretra médio-distal.

Magnetic resonance imaging in the diagnosis of pelvic floor disorders.

Vaginal prolapse due to pelvic floor dysfunction occurs frequently in postmenopausal women. The disease usually involves all compartments of the vagina, so that isolated defects are uncommon. In advanced disease, it can be difficult to identify which organs are prolapsed, owing to the large bulge in vaginal area. Accurate diagnosis of pelvic floor defects, actual prolapsed organs, and presence of any coexisting abnormalities are essential to correctly plan surgical reconstruction and minimize the risk of recurrence. In this review, we discuss the existing imaging modalities available to evaluate pelvic prolapse, emphasizing the role of dynamic magnetic resonance imaging.

How to prevent complications in vaginal surgery

Vaginal surgery complications can at times be difficult to manage. Clearly the best management scheme entails steps to prevent complications. This requires judicious planning preoperatively with detailed knowledge of this patient's case, operative anatomy, surgical indications and expectations, as well as prudent use of preoperative diagnostic testing. Thus, being prepared facilitates better recognition of intraoperative complications and subsequent treatment in an expeditious fashion. The most frequent and important complications of vaginal surgery are listed in the following sentences and are extensively discussed: 1)- Bleeding: most cases of bleeding that one experiences during transvaginal surgery are self corrected; 2)- Infection: since bacteria potentially contaminate the vagina, it is a frequent site of infections in the postoperative period; osteomyelitis of the public bone is an infrequent occurrence, however, with the increasing use of bone anchors in vaginal sling surgery, one must be aware of this complication; 3)- Bladder Injuries/Perforation: injuries to the bladder may occur during dissection of the vaginal epithelium off of the underlying perivesical fascia and bladder or during suture passage in cystocele repairs or incontinence procedures; 4)- Urethral Injury: intraoperative injuries to the urethra should be an infrequent occurrence due to its easy identification with a foley catheter in place; 5)- Ureteric Injuries: occur in 0.3 to 3 percent of patients undergoing gynecologic surgery; 6)-Bowel/Rectal Injury: should be an uncommon complication, yet when injury does occur, one must approach it seriously; 7)- Neurologic Injury/Postoperative Pain: sacropinous fixation can be complicated by nerve injury as the pudendal nerve lies in proximity to the sacrospinous ligament...