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

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Located in Atlanta, GA – Patients from 47 States and 45 Countries

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Mesh Complication Case Study #30

Up-Hold Mesh Complication

Initial Surgery: Vaginal Vault Suspension  (UpHold– Boston Scientific)

Post Mesh Surgery Symptoms: Mesh exposure, Husband pain with intercourse (can feel mesh)

Surgery to Repair Mesh Complications: Vaginal mesh removal

Pt is a 52 yr old female who had surgery for uterine prolapse and cystocele and SUI
Her original surgery included:

• LAVH (Laparoscopic Hysterectomy)
• UpHold vaginal vault suspension
• Posterior repair for rectocele
• TOT sling for SUI

Symptoms

The patient stated that after surgery approximately 1.5yrs ago she suffered from infection and mesh extrusion of the UpHold procedure. She underwent long term antibiotic therapy and also eventually needed hyberbaric oxygen therapy to treat the infection. The infection eventually resolved, however she was left with a mesh exposure at the top of the vagina. She had no symptoms and was very happy with her bladder function, i.e. no leakage, good control etc and therefore was very hesitant to have anything done about the mesh exposure (from the UpHold…not the sling). She was concerned though that if she became sexually active that she would have pain, as she did have pain on exam. She did become sexually active and did not have pain, however her partner can feel the mesh exposure and therefore she came in to see Dr. Moore and Miklos regarding the persistent mesh exposure.

 (Comment-The UpHold procedure is a piece of mesh that is placed at the top of the vagina to achieve vaginal vault support. It is attached up to the sacrospinous ligaments by a hook device called the Capio and then the mesh arm is pulled through the ligament.  It is not a sling for urinary leakage, it is for vaginal prolapse. It is made of a mesh that is medium in weight. Infection of the mesh itself is very rare and in this case was treated successfully, ie the mesh didn’t need to be removed, by antibiotics and hyperbaric oxygen therapy. Hyperbaric oxygen therapy has been shown to be very successful in treating surgical infections and in some cases of small mesh exposures)

Figure 1 – Picture of the Uphold Mesh and the Capio needle device that is used to attach the mesh arms to the sacropinous ligaments. The Capio device hooks around the ligament and then pulls the mesh arms through the ligament itself and the arms are then pulled to lift the top of the vagina up as that is where the wide mesh patch is placed.

On physical exam, the patient had COMPLETE exposure of the entire mesh at the top of the vagina.  This can be seen clearly in the above picture. Secondary to the size of the exposure, Dr. Moore and Miklos have recommended removal of the mesh that is exposed. The mesh will need to be tunneled up into where it enters the vagina on each side and excised inside this area so that the vagina can be closed and will heal over this area.  Most cases of mesh extrusion or exposure are typically very small (i.e. in the range of 1cm) and are considered minor complications and can easily be treated with a small procedure where the exposed mesh is excised and the vagina closed over the area. The entire mesh typically does not need to be removed and this usually takes care of the problem. In this case, the entire mesh is exposed, there is no tissue in-growth or incorporation of the body of the mesh, it is hanging freely in the vagina and therefore the entire graft needs to be removed. It does not seem to be actually giving any support to the vagina; therefore most likely she will not develop immediate return of her prolapse. If this did happen, Dr. Moore and Miklos would recommend laparoscopic repair, with abdominally placed mesh if necessary.

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.

For more information on Uphold Complications please click here.

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