Dr. John Miklos and Dr. Robert Moore – Vaginal Mesh Complication Surgeons
Internationally Renowned Vaginal and Laparoscopic Surgeons
Located in Atlanta, GA – Patients from 47 States and 45 Countries
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Mesh Complication Case Study #16
Apogee (Posterior Wall Mesh) Complication - Chronic Abscess/infection, Drainage from Buttock Cheek Tract
Surgery: Apogee (ie posterior vaginal wall mesh) used to fix rectocele enterocele and vault prolapse
Symptoms: Persistent sinus tract from right buttocks cheek, draining pus, buttocks pain, multiple abscesses x 2-3 years
Treatment: Complete removal of the posterior vaginal wall mesh and associated mesh arm from gluteal (buttocks) muscle
Patient is a 63 year old female who flew to Atlanta, GA from Baltimore MD to see Dr Miklos and Moore for treatment of what she had been told was a rectovaginal fistula which has persisted for almost 3 years.
Originally the patient had an Apogee (AMS) posterior vaginal wall mesh in 2007 in Maryland. (Figure 1) She was doing fine until 2009 when she began to have drainage from her sinus tract, which started out as a pimple/bump on her right buttocks cheek. She saw a general surgeon first and he thought it was simply an abscess and performed surgery.
Figure 1: Apogee mesh
She then a went to see a colorectal surgeon at Johns Hopkins University Hospital and he felt the first surgeon did not do an aggressive enough job. Her surgeon performed 3 different operations and on the last surgery he placed what is known as a Seton. When the operation was not found to be successful he referred her to another colorectal surgeon.
The new colorectal surgeon diagnosed her with a fistula and realized at this time there was mesh in the drainage sinus tract. He then recommended she see a urogynecologist in Maryland.
"I have seen 9 different surgeons over 2 years and you are my last chance!!" - Patient's statement to Dr. Miklos
This urogynecologist wanted to help but explained that she never had taken an Apogee out before. This urogynecologist then recommended another colorectal surgeon who did an exam and he agreed there was a mesh problem. He then referred her to another colorectal surgeon who in turn recommended she see a urologist who specializes in female urology.
She subsequently ended up seeking Dr. Mikos & Moore in Atlanta Georgia secondary to being recommended as some of the world’s experts in vaginal mesh complications. On examination it was obvious she had a sinus tract which was draining pus and bloody fluid from her right buttocks cheek. This is a very unusual complication from the Apogee procedure as the mesh is been shown to be effective and have low rates of complications, however with any mesh surgery (or any type of foreign body surgery such as a hip replacement) complications can occur and then need appropriate treatment by experienced surgeons when they do occur.
Figure 2: Sinus tract in patient’s right buttocks cheek
After an informed consent the patient elected to go to surgery and the mesh was removed. Dr. Miklos & Moore started the surgery at the opening of the vagina and needed to dissect the mesh from the overlying skin and away from the underlying rectum. At this point further dissection was done into the vaginal wall attempting to dislodge the mesh and clean up any further abscessed areas. After completing the dissection via the vagina then surgeons then turned their attention to the buttocks area and began by dissection through the buttocks (gluteal muscle) until the mesh was adequately dislodge and the mesh was removed.
Figure 3: Removed Apogee mesh
For better clarification to the reader where the mesh was dissected, Dr. Miklos & Moore placed a clean new piece of synthetic mesh through hole in the buttocks cheek and out through the hole in the vagina wall. This was done strictly for teaching purposes so other women might better understand the pathway of the original mesh and where the sinus tract developed.
Figure 4: Identifying the pathway of where the Apogee mesh was once and where the sinus tract & abscesses developed