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 #27

Avaulta – Chronic Vaginal Pain, Vaginal Mesh Extrusion

Anterior Vaginal Wall Mesh – Avaulta

Initial Mesh Surgery: Monarc TOT sling; Avaulta anterior vaginal wall mesh

Post Mesh Surgery Symptoms: Chronic vaginal pain, pain with intercourse, vaginal mesh extrusion

Surgery to Repair Mesh Complications:  Transvaginal approach to removal of the anterior vaginal wall mesh (Avaulta)

The patient is a 52-year-old female who had surgery in 2008 for the treatment of stress urine leakage and anterior vaginal wall prolapse (cystocele- bladder drop).  Her gynecologist performed a hysterectomy for abnormal uterine bleeding and her urologist performed a TOT sling for the stress urine leakage and an Avaulta of the anterior vaginal wall to support the bladder.

Within 3 months of the surgery she already developed chronic vaginal pain and had great difficulty trying to engage in intercourse (due to pain) and was aware that she had mesh coming through the skin of the vagina.  She went back to see her urologist who revised the areas where the mesh was coming through the skin of the vagina.  She stated her vaginal pain never went away and sex remained impossible.  She returned to her urologist and gynecologist only to be told there was nothing wrong.  Over 1 year went by until she sought the care of Dr. Miklos and Moore at Atlanta Urogynecology Associates. 

Dr. Miklos examined her and first noticed that she had 4 different areas where the mesh was extruding through the vaginal skin.  Examination of the anterior vaginal wall reproduced pain especially at the deepest edge of the Avaulta.  Touching the edge of the avaulta was not much different than feeling a taut guitar string.  Dr. Miklos and Moore suggested surgical removal of the anterior vaginal wall mesh known as Avaulta.

Patient went to the operating room in August 2011 and the mesh was removed by performing a midline vertical incision in the anterior vaginal wall (just underneath the bladder). Meticulous dissection was required to minimize trauma to the bladder or the urethra.  The mesh was identified and separated from the bladder and the skin of the vagina.  The mesh was then cut from its lateral attachment of the vaginal muscles i.e. the oburator internus &/or levator ani muscles and subsequently removed.  The vaginal skin was closed and the patient was admitted to the hospital for one night observation and sent home the next morning.  Her follow up and post-operative course will be posted later.

Fig. 1 - An Avaulta prior to transvaginal placement

Using the previous incision sites, Dr. Miklos and Moore approached the mesh removal laparoscopically. 

Figure 2: Prior to the dissection of the mesh,
you can see the mesh protruding

Figure 3: Dissection of the mesh from the bladder above
stick to define the mesh better

Figure 4: The removed Avaulta on this patient. Please note the decreased size of the mesh, which is caused by scar tissue. Also note the anchoring arms are not pictured here because they remain in the muscular vaginal walls of the patient.

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