De novo stress incontinence and pelvic muscle symptoms after transvaginal mesh repair.

OBJECTIVE: We sought to determine the rate of de novo stress incontinence, pelvic muscle symptoms, mesh exposure, visceral injury rate, and recurrent prolapse after transvaginal mesh repair. STUDY DESIGN: We conducted a retrospective review of 335 consecutive women with stage II or worse vaginal prolapse who underwent Prolift (Ethicon, Somerville, NJ) between July 7, 2005 and Jan. 31, 2008. RESULTS: In all, 71% underwent total Prolift, 20% anterior, and 8% posterior alone. Average age was 62 years and mean follow-up was 8 months. The intraoperative visceral injury rate was 6.6%, mesh exposure rate was 3.8%, and recurrent failure rate was 5.2%. The postoperative de novo stress incontinence rate was 24.3%. In this series, 18% of women had pelvic muscle symptoms postoperatively; 74% of these resolved within 6 months with conservative management. CONCLUSION: After Prolift, surgeons can expect a low rate of recurrent prolapse and mesh exposure. However, pelvic muscle dysfunction and de novo stress incontinence will be encountered postoperatively in a moderate number of women.

Commonalities of cerclage-related genitourinary fistulas.

OBJECTIVES: The purpose of this review was to identify common features of cerclage-related genitourinary fistulas. METHODS: A retrospective case series of cerclage-related fistulas was performed. The results were then pooled with available published case reports to identify common factors in these cases. Fistula location, surgical technique, and previous surgical and obstetrical histories were examined. RESULTS: From 2008 to 2011, 5 women were referred with vesicovaginal fistulas after cerclage. Within this series, 4 had prior cervical procedures, 3 had previous cesarean deliveries, and 4 had a McDonald cerclage in the antecedent pregnancy. When pooled with available data in 7 published case reports on cerclage-related fistulas, all 12 fistulas occurred in patients with prior histories of cervical procedures or cesarean deliveries. Specifically, of the 12 patients, 8 [66.7%; 95% confidence interval (CI), 0.39-0.86] had at least 1 prior cerclage and 10 (83.3%; 95% CI, 0.54-0.97) had at least 1 prior cervical surgery. When reported, 81.8% (95% CI, 0.51-0.96) had the McDonald technique used for placement of the current cerclage. CONCLUSIONS: The isolated and pooled findings suggest previous cerclage, any previous cervical procedures, and use of the McDonald technique are common factors in cases of cerclage-related genitourinary fistulas. This information may be useful when evaluating and counseling patients.

Effect of operative technique on mesh exposure in laparoscopic sacrocolpopexy.

OBJECTIVES: To determine if opening the vaginal cuff during laparoscopic sacrocolpopexy influences the rate of mesh exposure. METHODS: A total of 390 medical records were retrospectively reviewed for demographic information, operative technique, and relevant outcomes. RESULTS: Eleven mesh exposures (2.8%) and 14 suture extrusions (3.6%) were found, none involving visceral organs. Mesh exposure was more common when the vaginal cuff was opened, either during hysterectomy or when allowing transvaginal attachment of mesh in patients with a prior hysterectomy (4.9% vs 0.5%; relative risk [RR], 9.0, P = 0.012). In cases where concomitant hysterectomy was performed, a higher mesh exposure rate was seen in open-cuff hysterectomy (total vaginal hysterectomy/laparoscopically assisted vaginal hysterectomy) compared to supracervical hysterectomy (4.9% [9/185] vs 0% [0/92]; P = 0.032). Mesh exposure was more common when the mesh was sutured laparoscopically compared with transvaginally in patients undergoing open-cuff hysterectomy (14.3% [5/35] vs 2.7% [4/150]; RR, 5.4; P = 0.013). Permanent suture extrusion was significantly associated with laparoscopic versus transvaginal suturing of mesh (5.6% vs 0.6%; RR, 8.8; P = 0.010). Five patients underwent reoperation for mesh exposure, whereas most suture extrusions were asymptomatic; and all were managed nonsurgically. CONCLUSIONS: We found that preserving the integrity of the vaginal cuff led to a lower incidence of mesh exposure in patients undergoing laparoscopic sacrocolpopexy. When hysterectomy is indicated, a supracervical technique should be strongly considered as the mesh exposure rate was significantly lower. If removal of the cervix is indicated, the risk for mesh exposure remains low and should not preclude total hysterectomy, though transvaginal mesh attachment may be preferable.