While most clinicians remove vaginal mesh through the vagina, employing laparoscopy is feasible and safe, especially when there is limited visualization through the vagina, according to a case series presented at the 46th AAGL Global Congress on Minimally Invasive Gynecology.
“A combined vaginal and laparoscopic approach for excision of mesh, in my opinion, is superior because you can observe the bladder, the rectum and the structures that these mesh kits are attached to more clearly than a transvaginal approach would allow,” said principal investigator Rayan Elkattah, MD, assistant professor and associate program director of the Obstetrics and Gynecology Department at the University of Illinois College of Medicine in Peoria.
Because there are a variety of mesh products that anchor to various landmarks in the pelvis and are placed in different vaginal compartments, “laparoscopic excision is an additional tool that the gynecologist can use to render mesh excision more successful,” Dr. Elkattah told Contemporary OB/GYN. “This procedure is not necessarily safer than standard vaginal excision; however, it may widen the safety margin of excision by providing an abdominal view of what is happening on the other side of implanted vaginal mesh.”
To be successful, though, “one needs to identify the pelvic surgical landmarks, and particularly understand the margins of the planned dissection, and the anchor points of the mesh,” Dr. Elkattah said. “In other words, how far are you going to go to get things done? If you know your anatomy, and know where the mesh is attached, the likelihood of identifying and excising the mesh is better, easier and more complete.”
What Dr. Elkattah has discovered about these procedures from the medical literature is that the vast majority are done through a vaginal route. “Therefore, we questioned the efficacy and feasibility of doing them laparoscopically,” he said.
Since starting to perform laparoscopic excision of mesh 3 years ago, Dr. Elkattah has treated 20 patients. He and his colleagues began performing the procedure vaginally, then transitioned to a combined vaginal and laproscopic approach, which they found to be “very beneficial and very helpful,” he said. “But not much has been published in that regard.”
He noted that mesh-related complications are considered “a hot topic in gynecology and have significant liability implications.” How should patients who require surgical excision be managed and counseled? Are there management options available aside from a urogynecology referral or vaginal excision?
“Accordingly, we would like to expand on the indications for laparoscopic surgery,” Dr. Elkattah said. “All of these complications cause symptoms that would otherwise not be present in patients who had proper mesh placement
Dr. Elkattah said there is a large cohort of women who have mesh-related problems, and apart from vaginal excision, “we can now offer them a minimally invasive laparoscopic approach for symptomatic relief as well.”
The case series consisted of 13 patients, averaging 56 years of age, all of whom had a prior hysterectomy. Mesh surgery had been performed anywhere between 2 and 8 years prior before they presented with mesh-related pain. In addition, all patients experienced vaginal pain, and most had dyspareunia prior to presentation.
Dr. Elkattah noted that laparoscopic excisions of vaginal mesh are long procedures, taking an average of 195 minutes to complete. “However, this is not prohibitively longer to the point that poses a risk to the patient,” he said. The average estimated blood loss was 62 mL.
Concerning safety, there was one uncomplicated bladder serosal injury that was repaired intraoperatively.
Outcomes were primarily subjective. At their 6-week follow-up, patients reported a significant improvement in their vaginal and sexual pain levels of at least 70%. But objective scales for pain improvement were not incorporated.
When performing laparoscopic excision of mesh, Dr. Elkattah recommends the following:
1. Review all preoperative surgical reports detailing mesh placement.
2. Backfill the bladder to help delineate its borders.
3. Use a rectal probe to deviate the rectum.
4. Use a laparoscopic toothed grasper to allow for firm mesh manipulation.
Dr. Elkattah also said that long-term studies are still needed to evaluate how often prolapse recurs with mesh excision, and whether complete mesh excision is required for symptomatic relief.
Dr. Elkattah reports no relevant financial disclosures.
Elkattah R, Mohling S, Garcia B, Yilmaz A, Furr R. Outcomes for laparoscopic excision of vaginal and mid-urethral mesh. [AAGL abstract 29]. J Minim Invasive Gynecol. 2017;24(suppl):S12.