An unusual long-term complication of transobturator polypropylene mesh
Serious complications associated with surgical mesh for transvaginal repair of POP, as infections, vaginal mesh exposure, painful mesh shrinkage and dyspareunia, are not rare. A 48-year-old woman underwent the Perigee procedure because of a stage 3 anterior wall prolapse. Eleven months after surgery, the patient became suddenly unable to walk because of a strong pain to the left thigh root after running. The MRI revealed an external obturator left muscle hyperintensity consistent with muscular oedema; the patient was treated with oral corticosteroids with a complete resolution of the pain. We could hypothesize that the posterior arm of the mesh caused a laceration of the muscles of the obturator space with consequent oedema and pain. The use of the meshes in prolapse surgery can cause unexpected long-term complications.
KeywordsCystoceleVaginal surgeryObturator spaceVaginal meshComplications
It has been estimated that approximately 50 % of parous women suffer from pelvic organ prolapse (POP) and 11 % of all women will have surgery for POP or urinary incontinence , with many women having to undergo repeat surgery for failure of previous procedures . In particular, traditional anterior repair of cystocele utilizing the patient’s own tissue has reported high failure rates, mainly because of the attachment of poor-quality tissue to poor-quality tissue. In the last 10 years, the use of a non-absorbable synthetic mesh has been shown to reduce the risk of anatomic recurrence of the cystocele  and in particular for the case of women operated for prolapse recurrence , even if new data show that native tissue and vaginal mesh surgery have similar 5-year risks for surgery for recurrent prolapse .
One of the kits used for the repair of cystocele is the Perigee System (American Medical Systems, Minnetonka, MN, USA). The Perigee system is a kit that contains four side-specific, patented, helical needles designed for each anatomic pass through the obturator space to attach a graft to the pelvic sidewall in four locations in a less invasive, more simplified and standardized manner. The kit includes a soft, monofilament, macroporous polypropylene mesh that has four self-fixating, adjustable arms with special connectors to attach to the needles that are passed through the obturator space. Perigee system is considered safe and effective in the treatment of anterior vaginal prolapse .
This case report shows an unusual long-term complication of this transobturator mesh. In 2011, a 48-year- old woman underwent the Perigee procedure at the Department of Obstetrics and Gynecology of our Institute because of a stage 3 anterior wall prolapse following the POP-Q System classification (preop Ba point at + 4 cm). The woman decided for the uterine preservation. The mesh was attached to the pelvic sidewalls at the level of the bladder neck and near the ischial spine apically with needles passed through the groins and obturator space. The procedure was performed in 35 min with spinal anesthesia and the total blood loss was 50 ml. There were no complications during the hospital stay and the patient was discharged 3 days after surgery. At the follow-up visits 1 and 6 months after surgery Ba point was ≤1.0 cm.
The placement of meshes exposes the patient to specific risks, which in some cases are severe: infection, vaginal mesh exposure, painful mesh shrinkage and de novo dyspareunia are the most frequent. In particular, in July 13, 2011 the Food and Drug Administration stated that “serious complications associated with surgical mesh for transvaginal repair of POP are not rare”. For this particular case, our hypothesis is that this event could have been caused by the posterior arm of the mesh that caused a laceration of the muscles of the obturator space with consequent muscular oedema after physical activity. We cannot explain why the damage was only unilateral, but we can presume that an arm of the mesh has pulled from its previous position and caused this muscular injury even 1 year after the surgical procedure. We did not find similar reports in literature, so we consider useful to publish this case report as an unusual long-term complication of the meshes in prolapse surgery.
Conflict of interest
We declare that we have no conflict of interest.