Transvaginal, Abdominal Mesh Excision Compared


CHAMPIONSGATE, FLA. — There are trade-offs to consider in the surgical choices to excise mesh from a woman with prior abdominal sacrocolpopexy, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

Transvaginal approaches are less invasive but can take up to three attempts for full resolution of symptoms. On the other hand, one transabdominal laparotomy can and did resolve symptoms but was associated with more serious adverse outcomes, Dr. Mary M. South said.

Dr. South and her associates compared three techniques used to excise eroded mesh at Duke University Medical Center in Durham, N.C., between 1997 and 2006. The retrospective analysis included 17 women who had transvaginal surgery with endoscopy, 14 who had open transvaginal excision, and 7 who abdominal excision through laparotomy. All patients had a prior abdominal sacrocolpopexy and were identified from CPT codes, said Dr. South of the division of urogynecology at Duke.

“The objective is well defined, but this paper runs into trouble with the use of the term 'open' transvaginal excision,” said study discussant Dr. Robert W. Lobel, an obstetrician and gynecologist in private practice in Albany, N.Y.

Complications were the biggest distinction. Only minor postoperative complications were reported with either transvaginal approach, compared with more serious intraoperative and postoperative events with abdominal excision. For example, two patients in the laparotomy group experienced bowel injury during removal of adhesions; one required a bowel repair and the other, a resection. One patient had a postoperative wound infection with breakdown, and another was readmitted to the hospital for postoperative fever and antibiotics. Another abdominal excision patient had an acute coronary event and was transferred to the cardiology department.

Laparotomy was 100% successful in resolving symptoms, Dr. South said. The combined success with a transvaginal approach was 53%, including 7 of 17 patients in the endoscopy group and 9 of 13 patients in the open group (complete follow-up data was unavailable for 1 patient).

Of these 16 successful patients, 12 had symptom resolution on the first transvaginal excision attempt, 1 on the second attempt, and 3 on the third, Dr. South said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Lobel asked Dr. South why surgeons chose one transvaginal approach over the other. “This was a retrospective review. From 1997 to 2003, we [excised only] what we were able to visualize. Since then, we've only used the scope,” she said. “We believe the scope allows us to better completely remove the mesh.”

“I would definitely agree that a transvaginal approach is better than abdominal, but you did not have enough power to say that endoscopic removal is better than traditional transvaginal excision,” Dr. Lobel said.

Dr. Lobel also inquired if any transvaginal surgery patients had complete symptom resolution despite incomplete mesh removal. Of the 14 open transvaginal surgeries, 12 were incomplete removals, Dr. South said. “Both patients with complete removal had complete resolution symptoms.” Among the incomplete removals, seven reported symptom resolution.

In the group who had transvaginal surgery with endoscopy, there were two successes among 10 incomplete removal patients and five successes among five complete mesh excisions. Symptom resolution was unknown for the other two patients.

Despite the criticism from study discussant Dr. Lobel, Dr. South said, “We stick by our basic take-home message. If you completely remove the mesh, you will have complete resolution of symptoms. But if you only partially remove the mesh, it's hit or miss whether you will get resolution of symptoms.”

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