September 25, 2012 ~ Increasingly women are deciding that their synthetic surgical mesh placed to treat incontinence and prolapse is causing more complication than it's cured and are opting to have it removed, but a new report says the removal procedure may cause a host of internal injuries, especially to the urethra, or the smooth tube that carry urine from the kidney to the bladder.
Researchers from the Mayo Clinic and Spectrum Health Medical Group in Michigan have published their findings this week in the American Journal of Obstetrics and Gynecology.(here)
Researchers found the synthetic mesh kits using polypropylene mesh, promotes fibrosis or scar tissue, which may necessitate removal. This is unusual in it is one of the few acknowledgments that link polypropylene to fibrosis.
Vaginal mesh is inserted through the vagina to hold up prolapsed pelvic organs. A mesh sling may be used to support a sagging urethra and bladder to treat urinary incontinence and may be placed abdominally. Mesh complications include shrinkage, eroding into nearby organs, nerve and muscle pain, hardening, balling up, and causing infections, among other complications.
The plastic mesh utilizes anchors, usually metal, somewhere near the uterus to hold up the mesh. During a mesh removal, surgeons frequently leave behind the metal anchors since removal is considered too risky by many doctors.
In two cases profiled, surgeries for mesh and fibrosis removal resulted in damage to the urethra which was cut during the procedure. One woman undergoing the removal of a Prolift mesh (Johnson & Johnson), had her urethra transected and needed additional surgery and use of a catheter to assist with urination. Another patient had an American Medical Systems Apogee and Perigee mesh removed because it had eroded into her vagina and she was left with pain and incontinence.
“The literature suggests that 4.4% to 14.5% of patients have significant morbidity after mesh kit procedures, including mesh erosion, infection, pain, incontinence and recurrence of prolapse,” researchers noted. “The significant inflammation from host incorporation, relatively blind placement, and the proximity of urinary structures to supporting anchors predisposes the urethra to injury during mesh placement and removal.”
The FDA ordered 33 mesh makers to begin postapproval monitoring of complications last January, but those studies are not yet underway. The actual complication rate associated with surgical mesh for transvaginal or abdominal placement remains unknown.
The doctors involved in this study include Christine Heisler, MD, (Spectrum Group, Grand Rapids, Michigan) Elizabeth Casiano MD, Christopher Klingele, MD, John Gebhart, MD, Emanuel Trabuco MD.