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Mesh Complication Case Study #29

Complication of a Mini Sling (Ajust- Bard Urology)

Initial Mesh Surgery: Ajust Mini Sling for SUI

Post Mesh Surgery Symptoms: Severe Vaginal pain, Lower Abdominal Pain, Recurrent UTI’s

Treatment to Repair Mesh Complications:Removal of sling

This patient is a 48 yr old who presented with issues with pelvic pain and recurrent infections since her surgery in 2010. She had a hysterectomy for bleeding and problems with her uterus and had some minor issues with urinary leakage. Her surgeon told her they should just do a sling to take care of the leakage “since we are going to be in there”. Even though the leakage wasn’t bad, she agreed to do the sling at the time of surgery. Since surgery she has had issues with extreme pelvic and vaginal pain that radiates down into her legs and her buttocks. She also has had recurrent urinary tract infections. The pain did not improve and actually has worsened over time. She cannot have sex secondary to pain, has a hard time sitting or standing for any periods of time and had to quit work. She went back to her original doctor’s office six times for the infection and pain and they kept telling her it would get better and there was nothing wrong.

The patient did well for 8 years until July 2011 at which time she saw her gynecologist who referred her to a gynecologic oncologist (cancer surgeon).  The gynecologic oncologist referred her back to Dr. Miklos to address the problem.  The patient was taken to the operating room only 1 week later where the mesh was removed through miniature abdominal incision (i.e. laparoscopic).  Figure 2 shows the dissection of the mesh away from the vagina, Figure 3 shows the detachment at the sacrum and Figure 4 shows the mesh removed from the patient’s body.  Though there is no 100% guarantee that it will take away the pain most patient do very well with removal of the mesh.  

This patient is only a few weeks out and has not had a recurrence of pus formation or chronic pain in the vagina at this point; however she has yet to engage in intercourse.

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Figure 1 –Ajust Mini sling shown here prior to surgical placement

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Figure 2 - This illustration shows the position and placement of the Mini sling

She came to see Dr. Moore and Miklos secondary to their expertise with slings for urinary leakage as well as mesh complications. On exam it was very clear that the sling was the source of her pain and discomfort. The sling area could not be touched without causing the patient extreme pain. It could be felt that it was under a little tension, however she had more pain on each side of the vagina where the sling was anchored into the pelvic sidewall muscles. The Ajust sling has a somewhat large anchoring device that may have been causing the pain (see picture below).

Dr. Moore and Miklos took the patient to surgery and removed the entire Ajust sling, including the anchors that were attached to the obturator muscles on each side. In cases where the sling heals under tension and is just pulling on the muscles, the anchors may not be needed to be removed, ie just the vaginal portion of the sling removed and the tension on the muscles released and this typically takes care of the pain. However in this case, the sling was not found to be under a great deal of tension and it was felt the anchors may be causing some of the pain therefore every effort was made to remove them. In some instances they cannot be removed safely and have to be left behind.

It also should be noted that pain is a risk of ANY procedure for incontinence, traditional bladder tack, sling that uses fascia or sling that uses mesh. Mesh tape slings are considered standard of care and the FDA excluded them from their recent notification regarding mesh used vaginally for prolapse. However complications can occur with any procedure and the MOST important thing is to recognize the complication and either take care of it in a timely fashion or refer the patient to an expert so that the proper care can be given. Overall risks of pain requiring revision or removal of sling is less than 1%.

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Figure 3 – Picture of the entire Ajust sling removed from the patient. Note that the anchors were removed on both sides of the sling
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Figure 4 – A close up of the arrowhead like anchor on the removed Ajust sling

Comment from Dr. Miklos and Moore: The Mini sling for treatment of female stress urinary incontinence is the latest evolution of the tension-free vaginal tape sling. It is the least invasive sling available for treatment of SUI and in essence is a TOT sling, however it eliminates the need for passage of needles or mesh through the groins, which reduces the risk of groin or leg pain. It has been found to be very successful in many studies. Dr. Moore and Miklos utilize the minisling and have written several papers concerning the Mini-Arc sling (click here to view) and have had excellent clinical success with it. However, as with ANY surgical procedure, risks are present and complications do occur. The most important factor is that the complication is recognized and treatment is offered, or a referral is made to an expert that is used to taking care of the complication as in most cases the complications can be treated effectively with an outpatient procedure.

 

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