Mesh Complications in the Female Lower Urinary Tract

Abstract

Vaginal mesh has been introduced over the last two decades or more for the therapy of pelvic organ prolapse and for synthetic suburethral sling placement. While much of the data shows improved objective and some subjective success rates over other non-mesh-related approaches, the introduction of vaginal mesh does pose unique complications related to its placement. The implanting surgeon should be well aware of these complications as the management can be challenging and may require advanced surgical skills at times to avoid further adding to the initial presenting problem.

Commentary by Amanda S. J. Chung, The University of Sydney, Sydney, NSW, AustraliaRoyal North Shore Hospital, St Leonards, NSW, AustraliaConcord Repatriation General Hospital, Concord, NSW, AustraliaMacquarie University Hospital, Department of Urology, Sydney, NSW, Australia

Commentary

• Amanda S. J. Chung 

In this chapter, the authors have provided an excellent and thoughtful description of vaginal mesh complications, evaluation, clinical principles, and management options in the structure of four representative clinical vignettes:

• Urinary tract perforation of mesh, with note made of the difference between erosion and perforation

• Vaginal extrusion of mesh

• Pain without erosion or extrusion

• Fistula involving mesh

The authors are to be particularly commended on their considered approach to what can be highly emotionally charged and potentially litigious mesh complication scenarios.

The authors rightly acknowledge the presence of unique complications that can surround vaginal mesh implantation for the therapy of POP and SUI, and therefore the importance of the premesh implantation workup and counselling including appropriate consent process. Additionally, the authors highlight the need for appropriate follow-up and the importance of the implanting surgeon to be well versed on such mesh complications and their management following mesh implantation [23].

In the evaluation of all mesh complication clinical scenarios, a thorough history and careful examination is important, including cystoscopic and vaginal examination, to confirm whether the mesh is indeed implicated in the current clinical condition or whether it is simply an “innocent bystander.” This is particularly important in the climate of much hype and fear of mesh in some continents in recent years. Once thorough evaluation has been completed, the principles of management include the usual course of action, which include starting with more conservative management measures before more invasive mesh removal or revision measures are undertaken. A proportion of mesh complications can respond well to conservative treatment measures. An important tenet of care is to avoid creating further harm and thereby avoid compounding the initial clinical problems as much as is possible [24].

Indeed, no two mesh complications are exactly the same, and appreciation of subtleties and attention to detail are an asset to surgeons managing these difficult clinical problems. Furthermore, multidisciplinary co-operation, particularly in complex multiorgan cases, is valuable and such collegial relationships are highly desirable and to be fostered for the best care of our patients [25].