Large review builds insight on mesh removal outcomes

Atlanta-Findings from a study of patients who underwent surgical mesh removal over a 6-year period will hopefully help surgeons with their management decisions and counseling efforts, UCLA researchers reported at the AUA annual meeting in Atlanta.

"We were inspired to undertake this review because an increasing number of patients are presenting with mesh complications. However, the existing literature on management of these problems and the outcomes is limited. Therefore, we found it difficult to provide appropriate counseling," said first author Lisa Rogo-Gupta, MD, clinical instructor and fellow in female pelvic medicine and reconstructive surgery at UCLA.

"We hope that our study will bring reliable information that can be used by us and others to give patients realistic expectations on how they can be helped. In addition, we want to encourage the physicians who treat patients with pelvic floor disorders to collaborate and use all available therapies in order to bring the affected women improved quality of life."

The most common indication for surgery was mesh exposure or erosion (58%). Also common were complaints of pain or dyspareunia (34%) and de novo urgency, frequency, or incontinence (38%).

Multiple indications for surgery seen

"Our cohort represented a complicated group of patients because in about one-third of the procedures, a woman had multiple indications for surgery with some combination of mesh exposure, pain, voiding dysfunction, infection, and recurrent prolapse. These data offer an important message, which is that management of women with complications from mesh used in pelvic reconstruction is not just treating mesh exposure alone," said Dr. Rogo-Gupta, who worked on the study with Shlomo Raz, MD, and colleagues.

Subgroup analyses were also performed focusing on women who presented with pain because it was one of the most common symptoms necessitating mesh removal in patients without mesh exposure as well as one of the most distressing; nearly half of women reporting pain indicated it negatively impacted their overall quality of life, Dr. Rogo-Gupta reported.

However, there was good news from the review. With patients stratified by mesh type, 80% of patients reported their pain was improved after mesh removal regardless of whether they had pelvic organ prolapse mesh only, sling mesh only, or both. These results are consistent with data from a paper by Feiner and Maher (Obstet Gynecol 2010; 115[2 Pt 1]:325-30), who reported 88% of the 17 women with symptomatic vaginal mesh contraction in their series experienced substantial reduction in vaginal pain after surgical intervention, Dr. Rogo-Gupta noted.

The results from the UCLA review also showed that in a significant minority of women, multiple procedures may be needed to help achieve symptom resolution. In the series, two, three, and four or more mesh excisions were needed to achieve significant symptom improvement in 13%, 8%, and 1% of patients, respectively.

"Our findings encourage us to carefully plan treatment of patients with mesh pain and weigh the risks of aggressive mesh removal against the benefit of pain improvement and overall quality of life," said Dr. Rogo-Gupta.

"We suspect patient stratification based on the intensity, quality, and location of pain, as well as the time, since mesh placement will identify those who may require additional procedures."