7. Images from www.clevelandclinic.org Retropubic placementTransobturator placement

9. Image from www.ny-urogynecology.com

14. Haylen et al.: Neurourol and Urodynamics 2011

15. The generic term of “erosion” (medically defined as the “state of being worn away, as by friction or pressure”), doesn’t necessarily suit the clinical scenarios encountered. Its use has been abandoned.

16. NYU 2011

17. Maher et al. Cochrane Library 2013 Maher et al. 5 th ICI, 2013, 1377-1442 MUS POP Mesh  Mesh exposure 3%  Mesh perforation 0.5%

21. Surgeon Experience/Wisdom TVM Complications Patient Characteristics Mesh/Kit Properties Aggressive Marketing

29. 65 yo female had an anterior repair with mesh kit 3 years ago She began having pain and bleeding with intercourse 6 months ago Her partner can feel a scratchy sensation during intercourse Vaginal Wall Mesh Exposure Diagnosis

30.  Placement too superficial  Vaginal atrophy  Mesh folding  Mesh bunching  Incision dehiscence POTENTIAL CAUSES OF MESH EXPOSURE, EXTRUSION

31. Vaginal Wall Mesh Exposure Surgical Options *  Office trimming  Minor excision  Minor excision + flap mobilization and vaginal wall closure  Partial mesh removal  Mesh preserving approach with allograft coverage * Shah HN and Badlani GH: Indian J Urol 2012 † Terlecki RT and Flynn BJ: AUA update series 2010 Simple Technique: Transvaginal Complex Technique  Major excision + flap mobilization and vaginal wall closure  Near total mesh removal  Total (complete) mesh removal  Laparoscopic approach Least Invasive Most Invasive

32. vs.

33. 65 yo female had an anterior repair with mesh kit 3 years ago. She began having pain and bleeding with intercourse 6 months ago Her partner can feel a scratchy sensation during intercourse Transvaginal near-total mesh excision Vaginal Wall Mesh Exposure Operative Management

34. Exposure 5x10mm exposed Prolift PS

35. Paravaginal Hydrodissection Dissection Breisky-Navratil Retractor

36. Anterior Strap Transection

37. Posterior Strap Transection Deep Dissection Bladder Mesh

38. Prolift PS™ Explant

41. Bladder Mesh Perforation POP Mesh Kit

42. Open ended catheter in right ureter Anterior mesh arm Locking eyelet and apical fixating arm Example of bladder mesh perforation of AMS™ anterior Elevate Kit

43. Bladder Urethra LUT Mesh Perforation Mid-Urethral Mesh Sling

44.  unrecognized LUT perforation at the time of mesh implantation  unrecognized LUT trocar tunneling in the detrusor muscle  deep overlapping mesh placement  mesh insertion at the location of a recognized and repaired LUT injury POTENTIAL CAUSES OF LUT MESH PERFORATION Bladder Urethra Shah K and Flynn BJ: Int Urogyncol J 2013  primarily due to excessive sling tension  undue delay in sling lysis

45. Urethra High index of suspicion in patients with Hematuria, bladder pain, urgency, calculus adherent to the bladder wall LUT Mesh Perforation Diagnosis Terlecki RT and Flynn BJ: AUA update series 2010 Do not delay sling lysis Avoid urethral dilation Bladder Bladder incomplete emptying/retention Incontinence

46. Urethral Mesh Perforation after MUS Options Shah K and Flynn BJ: Int Urogyencol J 2014 Options Observation?? Transurethral removal – endoscopic scissors – laser – Other Transvaginal excision

47. Bladder Mesh Perforation after MUS Endoscopic Approach, * Davis NF et al: J Urol 2012 Holmium Laser  Location of mesh perforation  urethral (n = 2)  bladder (n = 10)  Perforated mesh excised  Perforated mesh excised in 19 mins (range 10-25)  Mesh resolution in 8/12 (67%) in a single operation  No. of laser p rocedures  1 procedure (8)  2 procedures (4)  3 procedures (1)  Open procedure (1)  Recurrent SUI 2/12 (17%)

48. Bladder Mesh Perforation after MUS Robotic Laparoscopic Approach * Ropuert M et al: Eur Urol 2010 Lap Excision *  Location of injury  vaginal wall (n = 29)  urethra (n = 0)  bladder (n = 9)  Lap excision  Lap excision 110 mins (range 50- 240)  Mesh resolution in 38/38 (100%) in a single operation  No. of Procedures 1 procedure (38/38) 1 procedure (38/38) Recurrent SUI Mesh exposure, 16/29 (55%) MUS perforation, 9/9 (100%)

49. Bladder Mesh Perforation after MUS Transvaginal/Combined Approach Shah K and Flynn BJ: Int Urogyencol J 2014  Location of mesh perforation Urethra (n = 14) Urethra (n = 14) bladder (n = 7) bladder (n = 7)  No major intraoperative complications  Mesh resolution in 20/21 (95%) in a single operation  Recurrent SUI urethra, 1/14 (7%) urethra, 1/14 (7%) bladder 0/10 (0%) bladder 0/10 (0%) MUS Complete Removal

50. 56 yo female had MUS placed for SUI 18 months ago She noticed blood in the urine 3 months ago and frequently has dysuria Vaginal Wall Mesh Exposure Diagnosis

51. Vaginal Wall Mesh Exposure Operative Management 56 yo female had MUS placed for SUI 18 months ago She noticed blood in the urine 3 months ago and frequently has dysuria Transvaginal near-total mesh excision, urethral repair

53. Management of Mesh Complications Operative Technique and Outcome Simple (n = 27) Complex (n = 49) 15 (56%) 3 (5%) Re-excision of mesh rates Hadley and Flynn AUA 2011

54. MUS: 60% of total cases POP Mesh Kit: 31% of total cases MUS + POP Mesh Kit: 9% of total cases Flynn TVM (MUS + POP Kits) Explant Case Log 2005-2013 Shah K and Flynn BJ: Int Urogyncol J 2013 Mesh Kit200520062007200820092010201120122013Total Midurethral Sling Kit261261416142531126 POP Mesh Kit1146681471865 MUS + POP kit000000271120 Total3716122024303960211

55. MUS TOT Mini

56. ArmsBody AP length 3 cm

58. Painful Mesh MUS, POP kit H & P H & P Operative report Operative report Cystoscopy Cystoscopy Urodynamics Urodynamics Vaginal ultrasound Vaginal ultrasound EUA EUA Potential Causes Work-up Non-Operative Therapy NSAIDS/Narcotics NSAIDS/Narcotics Gabapentin Gabapentin Massage Massage Physical therapy Physical therapy Trigger point injection Trigger point injection

59. Vaginal Wall Complaints Mesh Exposure Mesh Pain Management of Transvaginal Mesh Complications Infection Causes Pain Mesh Infection

60. TVM associated pain Treatment algorithm NSAIDS/Narcotics NSAIDS/Narcotics Gabapentin Gabapentin Massage Massage Physical therapy Physical therapy Trigger point injection Trigger point injection Non-surgical therapy Surgical therapy  Partial/minor mesh excision  Near total mesh removal  Total (complete) mesh removal  Robotic/Laparoscopic approach Least Invasive Most Invasive

63. Images from www.clevelandclinic.org Retropubic placementTransobturator placement Sling Revision/Removal for Mesh Erosion and Urinary Retention: Long-term Risk and Predictors. Funk et al. Occurs in about 1% of women undergoing MUS >

64. Transvaginal MUS Lysis Synthetic Sling Midline vaginal incision Sling ‘peeled’ off of urethra/incised Minimize lateral dissection Early: < 6 weeks Intermediate: 6 weeks – 6 months Late: > 6 months Midline and lateral dissection Mesh excision 1-3 cm Transvaginal urethrolysis More extensive dissection, excision Terlecki RT and Flynn BJ: AUA update series 2010

66. NYU 2011

67. TVT REINFORCES PUBOURETHRAL LIGAMENTS AND CREATES SUBURETHRAL HAMMOCK Iglesia 2010 1997 2003 2008 2008 TVT Gold Standard MUS is the Gold Standard for SUI TVM kit popular for all types of POP and as a primary procedure >1,000 complications reported in 2005-2008 from 9 manufacturers TVM Kit 2010 Ulmsten 1996 http://www.fda/gov/cdrh/safety/102008- surgicalmesh.html TVM Erosion rate 16% after POP surgery, no difference in cure rates FDA PHN Iglesia Study Chapple 2003

68. 2011 1/2012 7/2012 FDA Update FDA orders TVM manufacturers to go back and study their products Ethicon, Bard stop manufacturing POP kits and some mini-slings 522 Studies Ordered 2013 SUI and POP surgeries decrease, trends toward native tissue and biologicals Industry Reaction Mesh Hangover http://www.fda/gov/cdrh/safety/102012-surgicalmesh.html 5 million dollars awarded to plaintiff in California v. CR Bard, hospital and MD

69.  More women requesting native tissue repairs  More time spent obtaining informed consent  More time spent discussing TV adds and FDA PHN  Rise in urethral bulking and treatments for OAB  Lap/Robotic approaches with mesh gaining popularity

70. “It is the AUA’s opinion that any restriction of the use of synthetic polypropylene mesh suburethral slings would be a disservice to women who choose surgical correction of SUI.” Midurethral Sling Task Force This position statement was drafted by members Charles Nager, Paul Tulikangas, and Dennis Miller from AUGS and Eric Rovner and Howard Goldman from SUFU. Approved by the AUGS Board of Directors and the SUFU Board of Directors January 3, 2014. 1/3/2014