Urology & Kidney Disease News - Cleveland Clinic

40 Urology & Kidney Disease News
Female Urology
Excision of Extruded Vaginal Mesh
Howard B. Goldman, MD
Transvaginal prolapse repairs utilizing mesh recently have
become popular because of dissatisfaction with recurrence
rates of traditional transvaginal repairs. Along with the
increasing numbers of these repairs being performed we
have seen an increase in referrals for complications related
to mesh use. One of the common complications is extrusion
of the mesh into the vagina. In women who are not
sexually active this may be asymptomatic, but in some it
may cause vaginal discharge. If a woman is sexually active,
it may cause dyspareunia or pain to her sexual partner
during intercourse. Published extrusion rates are about
10% but with more experience and better vaginal wall dissection
techniques, the rate has dropped to the 2-4% range.
Nevertheless, given the large number of these mesh procedures
being performed, there are many women presenting
with post-operative vaginal mesh extrusion.
We have found that the majority of these patients can be
treated in a straightforward manner with excision of the
extruded vaginal mesh.
The technique involves:
1. Identification of the limits of mesh extrusion; 2.
Infiltration of the surrounding skin edges with a dilute
lidocaine and epinephrine solution; 3. Dissection of the
skin edges around the extrusion for just over 1 cm circumferentially
with development of skin flaps; 4. Careful
incision of the mesh; 5. Blunt and sharp dissection of the
mesh from the underlying bladder or rectum making sure
no mesh will be left at the skin closure site; 6. Closure of
vaginal skin.
(A DVD detailing this procedure was presented at the 2008
AUA meeting in Orlando.)
We recently completed a study, together with our gynecologic
colleagues, of our experience with 17 patients who
underwent vaginal mesh excision. The indications for
excision included mesh extrusion, chronic pain, dyspareunia
and vesicovaginal fistula. Most patients had
undergone a trial of conservative treatment - usually with
local application of hormonal cream. There were no intra-
or perioperative complications. At an average follow-up of 8
months, 93% were satisfied with the results of mesh excision.
While some of the cases were felt to be technically
difficult, most were accomplished without undue difficulty.
With the increase in the use of mesh for transvaginal prolapse
repair the number of complications related to mesh
placement has increased. In the majority of cases mesh
excision will alleviate symptoms and lead to a high degree
of patient satisfaction.
Key Point:
Many women are presenting with post-operative vaginal
mesh extrusion. We have found that the majority of these
patients can be treated in a straightforward manner with
excision of the extruded vaginal mesh. After completing
a study recently with gynecologic colleagues, we found that,
of the 17 patients who underwent vaginal mesh excision,
93% were satisfied with the results at an average
follow-up of 8 months.
Example of extruded vaginal mesh.
Dissection of vaginal skin off of extruded
vaginal mesh including an extra 1 cm in
circumference of unexposed mesh.
Incision of mesh and careful
dissection from underlying tissue.