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Transrectal mesh erosion remote from sacrocolpopexy: management and comment

      Sacrocolpopexy is an effective treatment for advanced pelvic organ prolapse with predictable anatomic and functional outcomes. We describe a rare complication of mesh erosion into the rectum and subsequent multidisciplinary management. Multidisciplinary, experienced subspecialty care can address difficult complications of pelvic floor surgery with a minimally invasive approach.

      Key words

      Surgical correction of pelvic organ prolapse increasingly utilizes artificial materials. Mesh erosion/extrusion is a well-recognized complication of mesh sacrocolpopexy. A 2004 review of abdominal sacrocolpopexy identified a median short-term mesh erosion rate of 3.4% (range, 0–5%).
      • Nygaard I.E.
      • McCreery R.
      • Brubaker L.
      • et al.
      Abdominal sacrocolpopexy: a comprehensive review.
      More recent data suggest that the rate could be higher, particularly with concurrent hysterectomy.
      • Cundiff G.W.
      • Varner E.
      • Visco A.G.
      • et al.
      Risk factors for mesh/suture erosion following sacral colpopexy.
      Correction of mesh complications can be complex and associated with poor functional outcomes.
      • Blandon R.E.
      • Gebhart J.B.
      • Trabuco E.C.
      • Klingele C.J.
      Complications from vaginally placed mesh in pelvic reconstructive surgery.
      We describe features of a late presentation of mesh erosion into the rectum, and details of management with a minimally invasive approach.

      Case Report

      A 51-year-old secundiparous woman underwent total abdominal hysterectomy with Burch urethropexy in 1998. She subsequently experienced vaginal vault prolapse with urinary retention and recurrent urinary tract infections. In 2000, she was treated with Mersilene mesh sacrocolpopexy and takedown of the urethropexy by laparotomy.
      In September 2007, at the time of a screening colonoscopy, the patient was found to have inflammatory changes that were associated with an exophytic lesion that was identified in the rectum. Other than constipation, she was asymptomatic at this time. Biopsy examinations of the area showed chronic nonspecific proctitis. Her condition subsequently was evaluated by a gynecologist who noted erosion of mesh material into the rectum and vaginal foreshortening. The patient was referred to a colorectal surgeon who, on office sigmoidoscopy, identified Mersilene mesh and suture material extruding into the anterior rectum approximately 8-10 cm from the anal verge (Figure 1). The patient was next referred to a female pelvic medicine and reconstructive surgery (FPMRS) specialist who identified stage I vaginal support and confirmed the finding of rectal mesh that was associated with the previous sacrocolpopexy. No mesh was seen within the vagina, but tenderness was elicited at the vaginal apex. The total vaginal length measured 6 cm. The recommendation of the colorectal and FPMRS surgeons was to remove the mesh.
      Figure thumbnail gr1
      FIGURE 1Screening colonoscopy
      Screening colonoscopy reveals mesh (m) in anterior rectal wall (r).
      Paine. Transrectal mesh erosion remote from sacrocolpopexy. Am J Obstet Gynecol 2010.
      The colorectal and FPMRS surgeons in a combined case performed laparoscopic-assisted excision of mesh (Figure 2). After laparoscopic excision of the mesh from 3 cm below the sacral promontory to the rectal defect, a minilaparotomy was performed to repair the rectal defect (Figure 3). Mesh attachment to the vagina was primarily to the posterior wall, with little mesh attached to the anterior vaginal wall. The attachments of the mesh to the rectum and vagina were taken down, which created a 2- to 3-cm rectal defect with the mesh removed through the rectal defect through the anus. A minilaparotomy was next performed to close the rectal defect adequately. Rectal integrity was confirmed with air insufflation. The postoperative course was complicated by wound seroma that was opened secondarily and treated with wet-to-dry dressings. After 9 months, the patient had recovered fully, with no new pelvic floor or bowel-related symptoms reported.
      Figure thumbnail gr2
      FIGURE 2Laparoscopic view of pelvis
      Laparoscopic view of the pelvis after division of the mesh (m) from the sacrum. The mesh can be traced down to its attachment to the anterior rectal wall (r). The bladder (b) is visible anteriorly.
      Paine. Transrectal mesh erosion remote from sacrocolpopexy. Am J Obstet Gynecol 2010.
      Figure thumbnail gr3
      FIGURE 3Rectal defect
      Defect (d) in the rectum is visible when a gloved finger passes through from rectal lumen. The right pelvic side wall (p) and bladder (b) are also visible.
      Paine. Transrectal mesh erosion remote from sacrocolpopexy. Am J Obstet Gynecol 2010.

      Comment

      Mesh complications are seen in many types of surgical repairs that involve its use, which include pelvic organ prolapse and hernia repairs. The precise cause of erosion/extrusion is unknown. Some complications may result from acute injury or misplacement during the index procedure; other complications are thought to occur over time because of infection or external pressure of the mesh on adjacent tissues. A study of 402 sacrocolpopexy surgeries found an overall mesh erosion/extrusion rate of 1.2%.
      • Stepanian A.A.
      • Miklos J.R.
      • Moore R.D.
      • Mattox T.F.
      Risk of mesh extrusion and other mesh-related complications after laparoscopic sacral colpopexy with or without concurrent laparoscopic-assisted vaginal hysterectomy: experience of 402 patients.
      More recently, Cundiff et al
      • Cundiff G.W.
      • Varner E.
      • Visco A.G.
      • et al.
      Risk factors for mesh/suture erosion following sacral colpopexy.
      identified a 14% mesh erosion rate with concurrent hysterectomy at the time of sacrocolpopexy.
      Between 2003 and 2006, the numbers of open and laparoscopic sacrocolpopexies (based on current procedural terminology codes 57280 and 57425, respectively) that were recorded in the Medicare database were fairly stable between codes 3502-5375 and 530-986, respectively. Given the morbidity of an open surgical approach and the technical challenge of a straight-stick laparoscopic approach, the use of sacrocolpopexy to correct pelvic organ prolapse has been limited. New technologies, however, may increase the prevalence of this procedure. Given that surgical complications stem from both absolute numbers of procedures done and surgeon experience, complications that are attributable to sacrocolpopexy could be expected to rise with increasing use. Transrectal mesh erosion is a recognized complication of mesh sacrocolpopexy. Surgeons who perform complex pelvic floor operations should be alert to such complications because they may be found well beyond the usual duration of postoperative follow-up examination. As such, one should have a low threshold to pursue the evaluation of unusual anorectal or gynecologic symptoms in patients who have undergone pelvic floor operations months or even years previously. Should such a complication arise, a minimally invasive approach is possible with acceptable functional outcomes.

      References

        • Nygaard I.E.
        • McCreery R.
        • Brubaker L.
        • et al.
        Abdominal sacrocolpopexy: a comprehensive review.
        Obstet Gynecol. 2004; 104: 805-823
        • Cundiff G.W.
        • Varner E.
        • Visco A.G.
        • et al.
        Risk factors for mesh/suture erosion following sacral colpopexy.
        Am J Obstet Gynecol. 2008; 199: 688.e1-688.e5
        • Blandon R.E.
        • Gebhart J.B.
        • Trabuco E.C.
        • Klingele C.J.
        Complications from vaginally placed mesh in pelvic reconstructive surgery.
        Int Urogynecol J Pelvic Floor Dysfunct. 2009; (Epub ahead of print)
        • Stepanian A.A.
        • Miklos J.R.
        • Moore R.D.
        • Mattox T.F.
        Risk of mesh extrusion and other mesh-related complications after laparoscopic sacral colpopexy with or without concurrent laparoscopic-assisted vaginal hysterectomy: experience of 402 patients.
        J Minim Invasive Gynecol. 2008; 15: 188-196