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

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Mesh Complication Case Study #25

Avaulta and TOT Sling Complication

Initial Mesh Surgery: Total Vaginal Mesh Procedure (Avaulta- Bard Urology), TOT Sling

Post Mesh Surgery Symptoms: Severe vaginal and buttock pain, Pain w/ intercourse

Treatment to Repair Mesh Complications: Vaginal mesh removal, TOT sling removal

Patient is a 56-year-old who had surgery by her general gynecologist for cystocele and rectocele 3 years ago.  She had Avaulta Mesh Repair for her rectocele and TOT sling for incontinence.  

Symptoms

Following surgery she suffered from a great deal of vaginal and pelvic pain, however she attributed this to the surgery.  She then began having vaginal bleeding and was found to have a mesh extrusion through the posterior vaginal wall (this is one of the most common risks of mesh surgery, however this by itself is a minor complication and typically easily treated by a minor procedure.  Typically the entire mesh is not removed, just the small exposure treated).  Her pain did not get better and despite multiple visits to her doctor, she was just told over and over “these things just take time to heal” and therefore she just stopped going as she wasn’t getting anywhere and not getting any answers.

 Vaginal and Low Back Pain - Her pain was originally in her lower pelvis and occasionally in the vaginal area and then it worsened over time told include her lower back, into the buttocks and then more in the vaginal area and felt pressure like she “was giving birth."  She had more pain when sitting and she had a hard time sitting or driving, as her buttock region would hurt the longer she sat.  She could not walk or exercise and the pain was waking her up at night.

Severe Pain with intercourse - Since surgery she tried having intercourse 2 or 3 times, however could not tolerate it secondary to extreme pain.

Treatment - The patient came in to see Dr. Moore and Miklos and was found to have good vaginal support and normal length.  On the surface and initial exam, everything did appear normal, however on more extensive examination the TOT sling as well as the posterior wall mesh (Avaulta) and the lateral arms of the mesh that penetrated the sidewall muscles her pain was reproduced. The sling itself as well as the lateral arms of the posterior Avaulta mesh procedure were found to be under tension and pulling on the vaginal sidewall muscles and palpation of these arms caused severe pain.

Dr. Moore and Miklos took her to surgery and removed the vaginal portion of the TOT sling and removed the entire posterior wall mesh, and released all arms and tension on the sidewall muscles and removed the arms where they entered into the sidewall muscles up higher in the vagina and near the opening.  A pudendal nerve release was not necessary as the arm had not been placed through the back of the sacropinous ligament, rather it was placed through the Ileococcygeus muscle (one of the levator ani muscles or pelvic floor muscles) near the ischial spine, making pudendal nerve injury much less likely. The patients pain most likely was generated from the tension on the muscles the sling and the arms of the mesh were causing.

Comment by Dr Moore—The mesh arms of the posterior system of any of the 1st generation mesh kits that use trocars or needles to place them through the groins or buttock cheeks typically do not need to be removed from the groin or the buttock cheek unless they are infected.  The pain is typically secondary from the arms pulling on the muscles from the vaginal side and therefore it usually is only necessary to remove the arms up to the point they attach to the muscle. This releases the tension and usually the pain improves. The newer generation mesh procedures such as Elevate and Pinnacle do not use this type approach and seem to have less issue with pain. The mesh itself is not causing the problem or pain, it is how it is placed, how it healed and how the arms are pulling on the muscles causing pain. Again, vaginal mesh used for prolapse, placed correctly, in the right patient, by an experienced advanced pelvic surgeon has very low rates of complications and has advantages of high cure rates.

The patient recovered well and although she still has some pain, the pain down the back of her leg and in her buttock cheek has resolved, the pulling pain in her vagina resolved and she is undergoing pelvic floor physical therapy and has a good outlook to be able to have pain free intercourse in the future.  She stated the day after surgery she could already tell a huge difference.

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