Table 2 shows the vaginal compartment from which mesh was removed, the specific brand of mesh removed, and the concomitant procedures performed at the time of mesh removal. In addition to those listed, three patients had rectovaginal fistula repairs and one patient had a vaginoplasty with a full-thickness skin graft for vaginal stenosis. The median length of time between mesh placement and mesh removal was 24 months (range 5–96 months).
Findings at the time of surgery revealed that in 63 of the 90 patients (70%), the mesh was not found to be lying flat or tension-free at the time of mesh removal. Descriptions of the mesh in the operative report from our mesh-removal procedure include: bunched, rolled, tight-band, wadded, gathered, or taut. Many different meshes were removed as seen in Table 2.
The most common presenting signs and symptoms were: pelvic or vaginal pain, 64% (n=58); mesh exposure, 62% (n=56); and a bulge sensation, 30% (n=27) with most patients reporting more than one symptom (see Fig. 2). Another common presenting symptom was dyspareunia, reported by 48% (n=43). Other presenting symptoms include recurrent infection, 9% (n=8); stress urinary incontinence, 28% (n=25); rectovaginal fistula, 3% (n=3); and defecatory dysfunction, 35% (n=32). Of the 56 patients who presented with mesh exposure, 26 had vaginal bleeding or bothersome vaginal discharge, 20 had pain or dyspareunia, four were bothered by the exposure with no specific symptom mentioned, one had recurrent vaginal infections, four had recurrent prolapse with an asymptomatic exposure, and one had stress urinary incontinence with an asymptomatic exposure.
Operative reports for the initial mesh placement surgery were reviewed before mesh removal and the expected location of the mesh noted. During the mesh-removal procedure, mesh was encountered unexpectedly in a second area of the vagina in 5% (n=4); for example, an operative report described mesh only in the anterior vaginal wall, but examination under anesthesia revealed mesh in the posterior vaginal wall as well. Mesh was encountered in the bladder in 1% (n=1) and in the bowel in 2% (n=2). The presenting symptoms most bothersome to the patient with mesh in the bladder were pain, urinary incontinence, and recurrent urinary tract infection. One patient found to have mesh involving the bowel reported recurrent prolapse and pain and the other patient reported pain and dyspareunia. Seven patients required reoperation after mesh removal at our institution. One patient was found to have mesh in the bladder that required subsequent cystoscopic laser removal. Two patients had an autologous fascia pubovaginal sling placed after the mesh-removal procedure: one had recurrent urinary incontinence after a portion of a synthetic midurethral sling was removed and the other had a planned staged procedure for removal of her mesh and then treatment of her incontinence. Four patients (5%) required an additional vaginal mesh-removal procedure.
Follow-up data were available for 84 of the 90 patients. The median follow-up length with interquartile range was 4 (2, 11.5) months. However, 29 of the 84 patients had 2-month follow-up, 29 had up to 6 months follow-up, eight had up to 1-year follow-up, and 18 had follow-up beyond 1 year. After vaginal mesh removal, 51% (n=43) had resolution of all presenting symptoms. Of the patients who presented with mesh exposure, 95% were treated successfully and did not require any further treatment. Persistent symptoms were reported by 51% of those who presented with pain (Fig. 2). The proportion of patients with each symptom before and after mesh removal were compared and there was a significant decrease in the proportion with each symptom after mesh removal (P<.01). Of the 43 patients who reported dyspareunia, 30% reported persistent dyspareunia at most recent follow-up.
Improvement in pain symptoms was analyzed as a result of the relatively high persistence of symptoms after surgery (see Fig. 3). There were 16 women (25%) who carried a preoperative diagnosis of a chronic pain condition and all presented with pain. Of these 16 women, six had little or no improvement in pain compared with five of the 39 women who presented with pain and did not have a chronic pain condition (37% compared with 13%, P=.06). Patients who had removal of all vaginally accessible mesh were not more likely to have a significant improvement in pain compared with those who had partial mesh removal (58.1% compared with 70.1%, P=.4). The number of prior mesh-removal procedures was also not associated with pain resolution. There was one patient who had de novo pain after mesh removal. She had an autologous fascia pubovaginal sling placed at the time of mesh removal and had persistent pain at the Pfannenstiel incision site at last follow-up.
In this study, complete resolution of all symptoms including vaginal discharge, bleeding, mesh exposure, and pain was achieved for approximately 50% of patients on whom follow-up was available. The symptom most difficult to relieve with surgical management was pain. Significant improvement or complete resolution of pain was achieved in 64% of patients, whereas 36% of patients had moderate or no improvement in pain after mesh removal.
The persistence of pain after mesh removal is consistent with several other series in the literature.2,6–10 The reported rate at which pain is relieved with surgical management in these prior reports ranges from 50% to 78% but little is known about risk factors for persistent pain. In our series, we found that patients with a chronic pain disorder were almost three times more likely to have continued pain after mesh removal than those without a chronic pain disorder (37% compared with 13%, P=.06). We hypothesize that patients with pre-existing pain syndromes have underlying pathophysiology predisposing them to persistent pain, even after mesh has been removed. In general, our approach is to manage expectations by explaining that mesh removal may be one component of a broader treatment plan, which may also include other modalities such as neuropathic pain medications, trigger point injections, and physical therapy.
Some patients who present with pain have a finding on examination that may explain their symptoms such as mesh that is bunched or folded or have an obvious mesh contracture. These women often have a single point or focal area that is painful on examination. Pain relief after mesh removal has been reported in up to 100% of women with obvious mesh contracture.9 However, in other patients, we found no anatomic abnormality on examination; the vagina was supple and the mesh seemed to be lying flat and tension-free, and yet they have had considerable pain since the mesh was placed. It is now our practice to perform removal of all vaginally accessible mesh on those without focal tenderness or clear bunching or folding of mesh and to perform a partial mesh-removal procedure on those with focal tenderness or other finding such as one tender arm of mesh. However, there are instances in which removal of all vaginally accessible mesh was the goal, but a partial removal was done as a result of the risk of increased bleeding or damage to the bladder or bowel during the dissection. At times, one must consider the risk of an intraoperative complication during aggressive removal of all vaginally accessible mesh, because it is not known whether this yields better outcomes than partial removal.
Firoozi et al11 reported on the operative management of complications from vaginal mesh placed for prolapse in a series of 23 patients. In that series, 11 (48%) patients presented with pain or dyspareunia and all but one patient had resolution of the pain or dyspareunia at last follow-up. The mesh removal technique for patients with pain as described in that study is similar to our practice. The median length of time between mesh placement and mesh removal in our study was 24 months. It was not reported in the Firoozi et al study, so it is possible that those patients had a shorter latency to mesh removal, which may affect the risk of persistent pain. It may also be related to the smaller size of that study or the specific mesh kits that were removed. The mesh removed in that study was from one of four types of mesh kits (Prolift, Apogee, Perigee, or Avaulta). In contrast, there were 10 different mesh kits in our series. However, it is important to note that any statement about the risk of persistent pain among different mesh kits should not be extrapolated from a case series such as this, because it is impossible to know the number of patients who received each kit and did not have problems. The role of our study is to provide information on symptom resolution in those women who require surgery for these problems.
Although 30% of our patients had persistent dyspareunia after mesh removal, many patients had not yet had intercourse at the time of last follow-up. Furthermore, it is not known whether this and other symptoms are likely to resolve with time.
This study describes the degree to which symptoms resolve in the short term in one of the largest series of prolapse mesh removal cases reported. There are, however, several limitations to consider in interpreting the results of our study. As a result of its retrospective design, intraoperative data and outcomes were not collected in a standardized fashion and a validated pain assessment was not performed. It is a custom, however, at our institution to have a very detailed operative findings section of the operative note, including, for example, details of the location of mesh exposure, presence or absence of banding and its location, and a detailed description of any prolapse present. In addition, a focus of our postoperative visits is to assess success or failure of symptom resolution. The International Urogynecological Association/International Continence Society graft complication classification system was published during the time when this cohort of patients had surgery and collecting information required by this classification system was not a part of our practice.12 Furthermore, as a tertiary referral center, it is difficult to obtain some components of the International Urogynecological Association/International Continence Society classification system, for example, T (time from mesh placement to initial clinical diagnosis of a complication). Many patients had a concomitant prolapse repair at the time of mesh removal and it is unclear how much this contributes to their symptom burden postoperatively. A quality-of-life assessment was not performed and the metric used for pain improvement was based at times on subjective phrases in the medical record. Because it is a case series, we cannot comment on the frequency or risk factors of complications of individual vaginal mesh kits. Similarly, because we do not place transvaginal mesh for prolapse, we cannot make any comparative statements about our cohort of patients and those who have transvaginal mesh placed and do not require additional treatment.
There are myriad clinical problems resulting from transvaginal mesh that clinicians must manage with little data or experience to guide them. The persistence of pain in 30% of patients suggests that treatment of persistent pain may be among the most difficult. In our experience, issues that may have an effect on outcomes of mesh removal include partial compared with complete removal and patient willingness and ability (financial, logistical) to pursue physical therapy, trigger point medications, and to tolerate neuropathic pain medications postoperatively. However, we were unable to analyze these variables as a result of the size of the study. This analysis suggests that patients with a history of chronic pain diagnoses may not be ideal candidates for the use of synthetic materials or implants and are at a higher risk for persistent pain after mesh removal.
In summary, there are many symptoms well treated with mesh excision. Vaginal bleeding and discharge, erosion, and urinary symptoms are relieved in the overwhelming majority. This analysis has demonstrated to us that we need to be careful to establish realistic patient expectations with respect to immediate and longer-term pain relief. It is our hope that with additional care, including the aforementioned treatments, our patients will experience at least adequate or complete relief of pain.
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© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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