Mesh complications Flashcards
You see a patient with mesh exposure in the vagina. What details do you want to know?
- mesh type, macroporous monofilament mesh. Other types should be removed
- mesh placement indication and location- to counsel on potential post op effects of removal
- signs of infection, pain, bleeding, discharge.
- Is she sexually active?
what is the rate of mesh exposure after MUS?
1-2 %
patient with prior SCP presents with back pain. What is your DDx?
sacral osteomyelitis
discitis
arthritis
muscle related pain
patient with prior SCP presents with back pain. what is the best imaging modality to assess for sacral osteomyelitis
non-contrast MRI
patient with prior SCP is diagnosed with discitis. What is your next step?
multidisciplinary approach: ortho, ID, neurosurgery
abx is the conservative option
patient with prior SCP is diagnosed with discitis and there is an abscess. What is your next step?
surgical drainage
remove the mesh
debridement of the involved spinal structures may be required.
Discuss risk of apical mesh exposure after Total Hysterectomy vs SCH.
Overall, there is an increased risk of apical mesh erosion with total hysterectomy vs supracervical hysterectomy or hysteropexy. With supracervical hysterectomy, the risk is approximately 2% or less. With Total, the risk is approximately 6%.
the concern is devascularized tissue during the hysterectomy
Ways to mitigate this risk include minimal use of electrocautery, imbricating cuff closure, with good approximating, without strangulation of the tissue, position the mesh so that it is not directly abutting the cuff.
Discuss absorbable vs non-absorbable sutures for SCP.
Absorbable- lower rate of suture exposure with no significant difference in anatomic outomes at 1 year
rate of urinary retention after sling on
POD1
2 weeks post op
6 weeks post op
what percentage under go sling lysis?
20% POD1
6% 2 weeks post op
2% 6 weeks
1% sling lysis
What is the success rate of MUS after prior anti-incontinence procedure?
what if the first procedure was a sling?
80% overall
73% for repeat MUS
your patient had a prior anti-incontinence procedure. She has recurrent SUI and you plan to do a MUS. success of TVT vs TOT
80% vs 50%
success of burch for recurrent SUI
after 1 prior surgery
after 2 prior surgery
after 3 prior surgery
80%
25%
0%
success of fascial sling for recurrent SUI
80% after 1 failed procedure
name 3 indications for fascial sling.
urethral recon or diverticulum
severe fixed urethra
prior mesh complication
declines mesh
name 3 indications for burch
coomined iwth abd or lap procedure
declines mesh
prior mesh complications
Describe the steps of the burch urtethropexy.
-small pfanny , lap/robotic
-enter space of retzius
-dissect the bladder away to expose the periosteum and coopers/pectineal ligament
-place 2 to 4 permanent or absorbable sutures lateral to the urethra in the endopelvic fascia of the anterior vaginal wall at the level of the mid and proximal urethra
-these sutures are then attached to cooper’s ligament and tied leaving a suture bridge to avoid over correction.
-
Describe the Latzko technique for fistula repair.
- Place a pediatric foley in the fistula tract.
- Hydro-dissect the epithelium from the fascia around the fistula
- Denude the epithelium in a 1-2cm circle around the fistula
- Place stay sutures at the apices of the vaginal epithelium for traction.
- Place a purse-string suture just outside the epithelialized tract
- back fill to assess for water tight seal.
- Place several layers of imbricating sutures to close the defect.
- Close the vaginal epithelium
- Cystoscopy.
what is the success rate of VVF repair?
up to 90%
Patient wants to see if VVF will resolve spontaneously.
What size fistula is acceptable for that?
how long would you keep the foley in?
<1cm
4 weeks
what is the risk of recurrent SUI after sling lysis?
40%
gastrograffin test?
24hr to pass the contrast into the rectum
risk factors for mesh exposure
smoking 3 fold increase
vaginal mesh placement - up to 40%, but they used type 3 mesh
transvaginal mesh erosion rate
5-10%
20-30%
vaginectomy vs colpopectomy
colpectomy is epithelial removal
vaginectomy is full thickness.
