Although the use of transvaginal mesh (TVM) had decreased significantly before its ban in April 2019, FPMRS specialists are still treating TVM complications and performing vaginal or open/robotic vaginal mesh removals (VMR) for mesh-related complications. 

In this work, we report a 14-year experience with VMR from a tertiary center with three FPMRS-trained surgeons.  We assess: pre- and post-procedure symptoms of patients undergoing VMR; indications for mesh removal and procedure approaches; as well as the complications of VMR and associated long-term outcomes. 

The purpose of this work is to contribute to the evidence base regarding approaches to TVM removal, as well as the associated long term patient outcomes, including the resolution of symptoms and need for subsequent procedures. These data can be used to inform preoperative planning, as well as patient counseling.

Following IRB approval, a retrospective review of non-neurogenic women undergoing transvaginal and abdominal/robotic VMR with 6 months minimum follow-up was undertaken. Mid-urethral sling (MUS) removals alone were not included. Using an electronic medical record, and a neutral reviewer not directly involved in the care of these women, data abstracted included demographics, provider notes, operative reports, pathology findings (including amount of mesh removed), outside medical records, peri-operative information, reoperations, and follow-up to the last clinic visit.

From 2006 to 2020, 133 patients were identified and 113 patients met study criteria with a minimum of 6 months of follow-up. Mean follow-up was 48 months (range of 6-138 months).  The median age of patients undergoing VMR was 59 years old (IQR 51-66), majority of whom were overweight with a median BMI of 27 (IQR 24-31).  65% of patients were sexually active at their initial visit.  6% of patients were current smokers and only 9% carried a diagnosis of diabetes mellitus at the time of VMR surgery at our institution.  We examined these baseline characteristics against the time to mesh excision, and there were no factors that reached statistical significance. 

Pre-operative VMR symptoms
The most common presenting symptoms were dyspareunia at 77% of patients and pain for 71% of patients.  49% of patients complained of recurrent UTIs at presentation. 41% and 45% of patients complained on history of stress urinary incontinence (SUI) and urge urinary incontinence (UUI), respectively.  Mesh erosion was found in 62% and 51% of patients had pain with palpation of the mesh. (See Tables 1 and 2)

VMR surgery & approach
The average time from primary mesh insertion for the treatment of POP to VMR surgery at our institution was 5.7 years (range 0.25-13.5 years). 42% of patients had a prior VMR at an outside institution. For our procedures, the majority were performed vaginally (84.5%). The average operative time was 195 minutes (SD+/- 84). Vaginal mesh was removed from anterior (60%), posterior (11%), anterior and posterior (10%) compartments.  Sacrocolpopexy mesh was present in 19% of patients, which was removed robotically or via an open approach.  The average blood loss for these procedures was variable at an average of 146cc (SD +/-99cc). 

Concomitant procedures performed at the time of VMR included: one mesh sling, two pubovaginal slings, 2 hysterectomies, 15 prolapse repairs (including anterior, posterior, and apical), and two fistula repairs (one vesicovaginal and one urethrovaginal). 

Intraoperative and perioperative complications
Two ureteral injuries and one rectal injury were repaired intraoperatively. One patient required two units of packed red blood cells on post-operative day one. Amount of mesh removed and its link to postoperative complications was evaluated, none of which reached statistical significance. 

Post-operative VMR symptoms
VMR resulted in resolution of pain in 50% of patients. Unfortunately, some patients had persistent pain (21%) and a few developed de novo pain (4%). More than half of the patients had dyspareunia resolution (52%), but 12% had persistent dyspareunia and 2% developed de novo dyspareunia. After VMR surgery, 12% required pelvic floor physical therapy for pain and dyspareunia.  

84% of patients who had initially complained of recurrent UTIs at presentation had resolution of their symptoms with VMR.  63% of patients who complained initially on history of SUI had resolution of their symptoms after VMR, while a small number of patients (12%) undergoing VMR developed de novo SUI.  

In terms of UUI, 26% had resolution of their symptoms, while 19% had persistent symptoms 11% developed de novo UUI. 10% of patients had to be placed on overactive bladder medications. (See Tables 1 and 2)

There were no significant differences in symptoms outcomes based on the location of and type of mesh excised.  (See Table 2).

Our study is one of the largest studies with long follow-up (minimum 6 months, mean 48 months,) evaluating outcomes of patients with severe complications from TVM (with and without MUS) and ASC (with and without MUS) that required surgical intervention(s).   Only one other study by Warembourg, et al has a mean follow-up of 41 months with an evaluation of outcomes for 69 patients. [1]  As far as we are aware there are only four other studies on this topic with patient follow-up greater than one year.  Similar to Warembourg et al, the most common indication for reoperation in our series was vaginal mesh exposure (62%).  In terms of pain, our postoperative results indicate that 21% had persistent pain, which is consistent with what Warembourg et al found at 22.6% of patients still having residual pain after VMR surgery, and Danford et al with 19% of their patients with persistent pain.[1, 2] Finally, like others have reported, several of our patients needed subsequent surgeries either for repeat mesh removal, recurrent prolapse or for urinary incontinence. [3]

VMR complexity requires advanced surgical expertise. It may result in multiple surgeries, and has an unpredictable functional outcome for pain relief, sexual function, and/or continence/prolapse status.

Warembourg, S., et al., Reoperations for mesh-related complications after pelvic organ prolapse repair: 8-year experience at a tertiary referral center. International Urogynecology Journal, 2017. 28(8): p. 1139-1151.
Danford, J.M., et al., Postoperative pain outcomes after transvaginal mesh revision. Int Urogynecol J, 2015. 26(1): p. 65-9.
South, M.M.T., et al., Surgical excision of eroded mesh after prior abdominal sacrocolpopexy. American Journal of Obstetrics and Gynecology, 2007. 197(6): p. 615.e1-615.e5.