Dr. John Miklos and Dr. Robert Moore – Vaginal Mesh Complication Surgeons

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Mesh Complication Case Study #18

UpHold Complication

Surgery:  Vaginal Vault Suspension  (UpHold– Boston Scientific)

Symptoms:  Vaginal/Buttock Pain, Mesh exposure, Bulge

Surgery:  Vaginal mesh removal, cystocele/vault repair

Patient is a 66 yr old female who had surgery for uterine prolapse and cystocele

Her original surgery included:

• TVH (total vaginal hysterectomy)
• UpHold vaginal vault suspension

Symptoms

The patient stated that she had an extreme amount of pain in the vagina and her right buttock cheek immediately after surgery that was not improving over the first 4-6 wks. She stated that the pain was very intense and shot down the back of her leg (the Pudendal nerve type distribution). She saw her surgeon several times and he told her that there was nothing wrong and that the pain should improve. She was having a hard time sitting or standing. At approximately 8 wks post-op the patient was bending over to pick something up and she felt something “POP” and felt a pulling in her vagina. Immediately after this happened, the vaginal, buttock and leg pain ceased and was alleviated.

 (Comment-Most likely what happened was that the UpHold tape was too tight and was pulling on the right sacrospinous ligament and the pudendal nerve on the right side….the Uphold is procedure that utilized a piece of mesh tape that is pulled THROUGH the sacropinous ligament on each side after grasping AROUND the ligament with a Capio needle driver. The center portion of the tape is wider and this is attached to the top of the vagina and supports the vaginal apex. There is no mesh in the anterior or posterior compartment therefore if patient has a cystocele or rectocele, this must be repaired with traditional placation techniques of their own tissue. In this case, the tape was pulled too tight and was causing irritation to the pudendal nerve….it released on its own [luckily] and the patients pain was relieved)

Despite her pain being better, she was still having vaginal bleeding and discharge and therefore was sent to Dr. Moore and Miklos for evaluation. On exam (see picture below), the entire vaginal tape was completely exposed (ie it is on the WRONG side of the vagina). The patient also has a persistent cystocele as this was not repaired at the time of her original surgery and the UpHold supports ONLY the vaginal apex or top of the vagina and does not treat cystocele or rectocele.

Dr. Moore and Miklos removed the exposed vaginal mesh and ½ of the arms up to the sacrospinous ligaments. Secondary to her pain being resolved and not having pain at the time of mesh removal, the arms did not have to be dissected up to the ligaments and removed in their entirety. If she still had leg and buttock pain, the arms would have had to have been removed from the ligament itself and released away from the pudendal nerve (this is a very complex surgery). Many times if it has been more than 6 to 12 wks after the original surgery and the arms have not been removed, then a chronic nerve injury could be set up and even if the arms are completely removed, the pain may not resolve.

After surgery, the patient did very well. She also had her cystocele repaired at the time of the removal and she continues to be doing well.

Below is a picture of an Uphold Device

 

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