1. Avoiding and Managing Mesh Complications after Surgery for Incontinence and Prolapse
M Karram MD
Director of Urogynecology
The Christ Hospital
Voluntary Professor of Ob/Gyn
University of Cincinnati

2. Learning Objectives Review appropriate techniques for sling placement
Discuss avoiding and managing intra-operative complications
Discuss diagnosis and management of postoperative complications
Discuss indications for current use of mesh in prolapse repair
Review how best to manage mesh complications

3. Types of Synthetic Midurethral Slings
Retropubic
Pre-pubic
Transobturator
Single incision mini slings
Home made slings

4. Intraoperative Complications
Bleeding
Injury to Bladder
Injury to Urethra
Injury to Nerves
Injury to Bowel

5. ANATOMY OF THE ANTERIOR VAGINAL WALL
Relationship of anterior vagina to posterior urethra
Distinguishing mid from distal urethra
Understanding lateral attachments of urethra and bladder

8. Anatomy of Anterior Vagina8

9. ANATOMY OF RETROPUBIC SPACE
Anatomy of Bladder and Urethra
Vascular Anatomy
Potential for Bowel Injury
Anatomy of Anterior Vaginal Wall

17. TVT with bladder perforation

18. Rinehart; calculi

19. Transobturator Approach
Anatomy of obturator foramen

20. Obturator Canal Obturator Foramen
Ilium
Obturator Foramen
Ischiopubic Ramus
Pubic symphysis
Ischium

21. M. OBTURATOR EXT
M. OBTURATOR INT

22. Obturator Foramen
Covered by a tough membrane that is continuous with periosteum and tendinous attachments
The obturator membrane covers the obturator muscle
Obturator canal (sometimes referred to as the fossa) is 2 - 3cm long, beginning at anterolateral opening of membrane
Canal is transversed by obturator nerve, artery and vein, vessels pass downward into the thigh

23. Obturator Foramen Obturator muscles:
The medial adductor compartment - all innervated by obturator nerve
adductor longus, brevis and magnus
gracilis and pectineus muscles

24. Obturator Foramen Obturator vasculature:
Obturator artery passes through obturator canal and divides into medial and lateral branches
Upon entering canal, divides into anterior and posterior
Anterior branch innervates adductor longus, brevis and gracilis

25. Transobturator Landmarks
Adductor longus
Urethra
Obturator canal
SAFE ENTRY ZONE of TRANSOB NEEDLE

26. Needle entry & path

27. Transobturator Anatomy Anterior Vagina

28. Complications of Synthetic Slings
Postoperative complications
Voiding Dysfunction
Irritative Symptoms
Trade in Prolapse
MESH COMPLICATIONS
Pain
Recurrent UTI’s

29. Eroded OB tape

30. Eroded TVT; urethrovaginal Fistula

31. TVT SECUR in Urethra

32. Surgery for POP; What is the Future?
Prevelance will continue to increase
Will kits and mesh become standard of care?
Less invasive durable repairs will be developed
Increased understanding between functional derangements and anatomic descent

33. Master Class;Ob/Gyn News
In US from 2005 to 2007 a reported total of 994,890 surgeries using industry driven mesh were performed
The impetus for mesh usage was based on the FACT that conventional pelvic floor prolapse repair has an estimated failure rate of 30% to 50%

34. ↑ $$
↑ Morbidity
↓ Prolapse
Recurrence??
Mesh Kits

35. RCT of Mesh vs. No-Mesh for Cystocele Repair, cont.
Mesh group: lower PVRs; higher de novo SUI (10% after anterior repair vs. 23% after mesh).
18 of 104 (17.3%) mesh exposures; only 4 were symptomatic. 10/18 had resection; 7/18 had persistent exposure at 12 months.
Reoperations (mostly TVT): 6.2% in anterior repair group and 4.8% in mesh group (p=NS).
Hiltunen R, et al. Obstet Gynecol. 2007

36. Serious Delayed Complications with Mesh in RPS
Use of mesh, especially polypropylene, in the transvaginal repair of anterior and posterior vaginal wall prolapse results in vaginal erosion, with associated bleeding, drainage and dyspareunia, in 5% to 17% of cases. Some cases are asymptomatic and some only need trimming but re-operations can result. Vaginal pain however is a particular and new concern.

39. Mesh Erosion; vault suspension

40. Mesh in Rectum

41. G Fields

42. Mesh removal after vag hyst

43. Quote
“There is no condition or disease that cannot be made worse by surgery”.
Ulf Ulmstem