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 #23
Complications of TOT Slings
(Gynecare –TVT-O; AMS – Monarc; Colpoplast – T sling)
Initial Mesh Surgery: TOT (Transobturator) Sling
Post Mesh Surgery Symptoms: Vaginal pain and dyspareunia (ie pain with intercourse)
Surgery to Repair Mesh Complications: Transvaginal approach to removal of the portion of the sling that traverses from pelvic sidewall to pelvic sidewall.
This patient is a 52-year-old woman who presents from southern Illinois who had a TOT sling performed in May 2007 in Canton, Georgia. After the initial surgery she was having problems with pain and general discomfort in the vagina. She went back to her original gynecologist who performed the surgery and he told her that it was scar tissue but didn’t offer any solution.
She moved away to Illinois and decided to pursue another physician to help her. She went to St. Louis, MO where she saw one of the areas pre-eminent urogynecologist who diagnosed her with IC or interstial cystitis. He placed her on various medications (Elmiron) to treat the IC. When the pain continued he referred her to a plastic surgeon for trigger point injections for his suspected diagnosis of nerve entrapment. This plastic surgeon referred her to another plastic surgeon that said, “They are all quacks” meaning gynecologists and the patient was then referred to a world-renowned urologist in female incontinence in St. Louis. The urologist stated: “I don’t think you have IC and ordered a pelvic ultrasound”. The ultrasound revealed a thickening underneath the bladder and told the patient she had two choices to come back to him for treatment or go back to the urogynecologist.
NOTE (Dr. Miklos & Moore): When a sling is performed, the sling does not elevate the bladder but instead the urethra. The thickening underneath the bladder has nothing to do with the sling procedure.
The extremely frustrated patient contacted Dr. Miklos by email and Dr. Miklos explained to her based on the information she presented: 1) she did not have IC and 2) she didn’t have pain before the sling and after the sling she had pain thus it was mostly likely the sling that was causing the pain. The patient set up an appointment and came to Atlanta within the month. Examination revealed point tenderness exactly where the sling extends across the vagina underneath the urethra. The patient agreed this was the pain she experience and which is exacerbated with intercourse.
The patient was taken to surgery the next day and an incision was made just underneath the urethra (where the sling was placed). Dr. Miklos & Moore extended the dissection laterally to the vaginal side walls, freed up the sling away from the urethra and cut the sling as laterally as possible. This removed all tension across the ceiling of the vagina and underneath the urethra. The patient spent the night in the hospital and traveled back to St. Louis the following day. The next day she could already feel tension and pain relief in her vagina. We will follow-up in 12 weeks to let you know if her pain has completely resolved.
Figure 1 - This is the initial dissection of the vaginal skin away from the sling. The sling is noticeable here to the educated observer but it is densely scarred to the urethra above. The sling now needs to be meticulously dissected away from the urethra above. There is SEVERE tension on this sling horizontally, which creates pain for the patient. (The yellow tube is a catheter going into the urethra.
Figure 2 - The sling is completely dissected away from the urethra above and partially away from the sidewalls. Here Dr. Miklos is stretching the sling so one can view the sling more readily.
Figure 3 - The sling is completely dissected away from the urethra above and partially away from the sidewalls. Here Dr. Miklos is stretching the sling so one can view the sling more readily.
Figure 4 - Here the vaginal portion of the sling has been completely removed. It measures approximately 4 cm or 1.5 inches. The removal has relieved 4 long years of patient pain.