ST. LOUIS — Complaints of vaginal discharge, bleeding, and/or general vaginal discomfort in a patient who has undergone sling placement may signal vaginal mesh erosion.
Patients with vaginal mesh erosion might also note that their partner “feels something” in the vagina during intercourse, Dr. Ginger Cathey said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.
Vaginal mesh erosion occurs in about 0.5% of synthetic sling patients, according to the most recent reports in the literature, and in most cases, the mesh erosion will be quite apparent although, in some cases, the mesh fibers can be felt, but not visualized, said Dr. Cathey, a practicing urogynecologist at Baylor College of Medicine, Houston.
Bladder and urethral mesh erosions are far less common, with only case reports appearing in the literature. Patients with bladder or urethral erosions might present with complaints of recurrent urinary tract infections, irritative voiding symptoms such as frequency and urgency, and hematuria. Consider these types of erosions if you have a sling-placement patient who complains of greater frequency and urgency than before the procedure and who has normal post void residuals, Dr. Cathey advised.
Management of vaginal mesh erosion – which usually occurs in the midurethral area, can include local estrogen, especially in cases where a few fibers can be palpated, but not seen, or when the patient is hesitant about excision. However, Dr. Cathey has doubts about the ability of local estrogen to promote re-epithelialization. Excision, she said, is her preferred approach to management of vaginal mesh erosion, and it can generally be performed in the office. “It's very rare that I would take a sling erosion back to the operating room to excise it,” she said. Even if a patient has undergone excision and comes back saying they still feel something, you may be able to remove the remaining fibers in the office by using a colposcope and a suture removal kit to tweeze out the fibers and snip them at that time.
Treatment of larger areas involving exposed tissues or recurrent erosion is best treated by advancing the vaginal epithelium to cover the defect, Dr. Cathey said, noting that use of a Martius graft in such cases would be overkill, but that such a graft would be reasonable in cases of urethral erosion in which the patient has developed a urethral-vaginal fistula.
For bladder or urethral erosion, avoid urethral dilation, which can loosen the sling, but which also places the sling closer to the urethra thereby increasing the potential for more erosion, Dr. Cathey explained.
Try to manage these patients “as minimally invasively as possible,” she said.
Separation of the mesh from the bladder can be challenging, but it can be accomplished using laparoscopic or cystoscopic equipment, or by mini-laparotomy, she noted.
“If you want to resect all the mesh fibers, it's really important that you put counter-traction on the mesh before cutting it,” she said, noting that the simplest approach is to distend the bladder and to place a 5-mm suprapubic trocar through the bladder, using it to apply traction while you take the endoscopic endoshears and trim the mesh as closely as possible.
If a patient treated for bladder or urethral erosion presents with recurrent irritating voiding symptoms, be sure to evaluate the contralateral side for a second erosion, she said.
Dr. Cathey disclosed that she is a consultant for Bard Medical.