Dr. Twiss On Transvaginal Mesh, Removals, Concerns and Consent
Christian Twiss, MD is a surgeon at the University of Arizona’s Department of Surgery, division of urology. He is a Board Certified urologist by training with a sub-specialty and certification in female pelvic medicine and reconstructive surgery (FPMRS). Dr. Twiss studied with Dr. Shlomo Raz at the University of California Los Angeles (UCLA) between 2006-2008.
“I miss him, I’d do it all over again in a heartbeat,” he says. “He’s given me helpful tips and tricks. It’s easy to put in mesh but it can be quite a difficult and complicated procedure to take out mesh depending on what type of mesh is put in.”
Dr. Twiss says half of his practice these days is mesh removals.
He talked with Mesh News Desk Editor, Jane Akre.
Q: A lot of doctors do partial mesh removals, why do you think Dr. Raz seems to be able to remove more mesh completely than other doctor can?
“You need to be consistent and you need to be willing to literally go deep into the pelvis to remove the mesh from its attachment point. And different surgeons have different degrees of comfort doing that and when you go deep into the pelvis to take out mesh you definitely can incur some risks, particularly hemorrhage. There are a lot of big blood vessels deep in the pelvis and it can be intense getting the mesh out. I also know there are a lot of patients who’ve had these partial mesh excisions and they continue to have pain and discomfort until somebody goes deep in the pelvis to get out the mesh arms. Not everybody is comfortable doing that. It’s not easy. My experience is that it’s better to go in all at once to get the whole implant than piece by piece by piece. Sometimes you go in and cannot find it anymore, whereas, if you could take out the whole implant as one you can find the mesh in an easy location and follow it down to its insertion point and remove the whole thing. Dr. Raz has expressed that to me it’s better to take it out at once.”
Q: I think he said it acts like shrapnel when you leave lose pieces in the pelvic region. Who knows where it’s going to go? Is that your experience?
A: “Yes absolutely, but unfortunately sometimes that’s necessary, sometimes there is a small piece you can’t get out. Sometimes there will be a small piece near a major vessel and you keep trying to get it out but if you get significant bleeding from that major vessel sometimes you have to take out what you can and over sew the vessel. Every patient is a little different so you don’t know what you can expect. It just takes patience and persistence to get it out.”
Q: Do you have access to a translabial ultrasound?
A: “We started doing that in conjunction with our radiologist here. It can be very helpful especially in those patients who have had a prior mesh excision. It can help us identify which arm is still there and which arm is not still there. You kind of know where to go to find that residual piece of mesh. It also gives me objective confirmation there is definitely mesh there versus some scar tissue. So we are definitely finding it helpful using the translabial ultrasound.”
Q: Is that in every case prior to surgery?
A: “Not every case. There are some clear cut cases if someone had a sling put in, you can palpate the sling and no one has worked on the sling so you know where to find it. I tend to use the translabial ultrasound on patients where, number one, they may not know what procedure they had or what was done, if we do not know if there is mesh or where it’s located. Those are the cases we find translabial ultrasound most helpful.”
Q: Are you still using transvaginal mesh?
A: “Less and less. I kind of cherry pick patients for that. Since the FDA warning came out I did read the recommendations and for transvaginal mesh for prolapse. I think the placement for that has fallen down to the wayside. I’m definitely putting more mesh in through the abdominal route with the sacrocolpopexy procedure and I don’t push mesh on anybody. I offer everything – mesh versus non-mesh versus the old fashioned repair with sutures.
“The problem being as we back off from mesh there is a potential for increasing failure rates. Some people say I don’t care, I don’t care if I have a high risk of failure, I don’t want mesh in me. I say fine, so I don’t push mesh on anybody. I consider my role as trying to educate the patient on the options they have and I really want the patient to kind of help me figure out what’s best for them. I started doing the old fashioned harvesting the patient’s own tissue for their sling for example, the autologous pubovaginal sling, an operation that has fallen by the wayside I think is seeing a comeback because of this reason.
And I have a bigger and bigger series of patients who don’t want mesh or have had a mesh disaster and don’t want mesh anymore. We offer those patients their own fascia the graft for a sling or for prolapse repair or we use cadaveric fascia lata or another biologic implant. I counsel the patients – here are the numbers we have, if you are willing to accept a higher potential risk of failure, I’m willing to do the operation – because the patient needs to be happy with their choice.
“And I think part of the reason we have a lot of these mesh issues is because mesh was kind of pushed on patients and it was put in and then we have problems and nobody knows what to do about them or there is not enough experience to deal with the problem with the mesh so the patient feels abandoned and essentially they have been abandoned. And so it’s also important if you are going to use the material you need to feel comfortable fixing any problems that happen with it and be committed to the patient.”
Q: We heard during the mesh trial (Ethicon) that the manufacturer (Johnson & Johnson) never trained doctors on how to remove it.
A: “To be honest if I do a potential mesh implant I’m not comfortable putting in anything I’m not confident I can get out entirely. I started out cutting my own piece if I was going to put in mesh. I was resist to all these kits on the market because I personally did not agree with the method with which they were being placed, with these large needles that were a blind passage, I don’t like that. It disagrees with my concept of what surgery should be. Surgery should be careful placement of whatever you’re putting onto the anatomic structure. And for that reason I rejected a lot of those kits, I never adopted that procedure. I was always in favor of doing a careful dissection and knowing exactly where to place this material because, God forbid, if there is a problem you as a surgeon should be able to go back in and get the whole thing out.
“So that’s kind of my policy. If I’m going to put mesh in a patient, and that is what they’d like, I don’t use an implant I’m not certain I could get out if I had to. And I haven’t really had to do that very often, in a handful of cases, but when I’ve had to do it I’ve been able to get it all out including the anchors. To me that’s important because I don’t want to be the person who is abandoning my patient and saying I can’t help you. I have to sleep at night. I can’t live with that.”
Q: Informed consent is always the issue that most people complain about, they had no idea. What are you telling women prior to surgery about mesh to have a full and complete informed consent?
“So I’ve adopted a strategy where I educate the patient about all the options – there’s transvaginal placement, there’s mesh versus non-mesh and I really want to hear back from the patient about what they would prefer. I try to educate them about the main risks and benefits of each because the non-mesh procedures also have potential risks and complications associated with them. There is no complication-free procedure. I educate the patient and figure out what they would prefer and where they’re leaning and sort of help them along the path of decision making. I found that to be the best. I think it’s collaboration between the patient and the physician, that’s the way it should be.
“I’ve moved from booking surgery quickly to – We’re going to talk about the broad strokes available and you’re going to come back for a whole other visit to sit and talk about what you’re most comfortable with. I now have a separate office visit to talk about options. I definitely allocate more time counseling patients about these issues. If we are going to do a mesh procedure, the main issue with mesh is vaginal mesh exposure which could lead to repeat operations and some patients experience pain and discomfort related to the mesh.
“And definitely we’ve learned if you are going to place mesh you should use the lightweight, low weight, minimal mesh implant. In other words, don’t put in too much, it should be the least dose to get the job done. I counsel patients about all the risks in the FDA warning, I also counsel them about the other options, biologic materials, and our experience with biologic materials. Basically there seems to be less potential risk of exposure and if it does it tends to heal over on its own. That’s an advantage; the disadvantage is there seems to be lower success rate as compared to a permanent mesh implant. And that’s fine. I’ve had a lot of patients come in who say I’m not comfortable I don’t want to touch it with a 10 foot pole. That’s fine. I’ll offer them their own tissue or a biologic implant. This is for prolapse by the way.
“For sling surgery it’s either mesh versus your own tissue. For a simple anti-incontinence procedure, still the majority of pelvic surgeons regard a synthetic mesh as the standard of care. If it’s placed properly it’s efficacious in the long term. There’s good data on that with relatively low complications and morbidity. Nonetheless you could still make a sling with your own tissue and accomplish the same goals. So it really should be up to the patient. And the issue with that is if you do an autologous sling they need to be aware you have a larger incision from the belly where we harvest the graft you’ve got to recover, which takes longer. But if the patient is happy with that and they’re happy to be without mesh I’m happy to offer it. The patient needs to be an active participant so that they are comfortable with what’s being done. And they need to be educated and I think that’s the issue here, patients have not or were not counseled regarding the risks of mesh. That’s problematic. You can’t do an operation on someone who has not been counseled about the potential risks they face.”
Stay tuned for Part Two Wednesday here.!
Associate Professor of Surgery
University of Arizona College of MedicineDirector of Female Urology, Pelvic Medicine, and Pelvic Reconstructive Surgery
Department of Surgery, Section of Urology
University of Arizona Medical Center
1501 N. Campbell Avenue
P.O. BOX 245077
Tucson, AZ 85724-5077