Female Pelvic Medicine & Reconstructive Surgery:
1Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California, San Diego, La Jolla, CA; 2Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser San Diego, San Diego, CA; 3Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Riverside, Riverside, CA
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: None.
To report the prevalence of and risk factors for mesh erosion after minimally invasive sacrocolpopexy (MISC) using polypropylene mesh.
MATERIALS AND METHODS:
This was a retrospective chart review of all MISC performed at the two institutions in our fellowship-training program between 11/2004 and 2/2009. Baseline and historical characteristics of subjects, and surgical procedures including hysterectomy were evaluated as potential risk factors for mesh erosion. MISC was performed as a robotic assisted laparoscopic sacrocolpopexy (RALSC) or a standard laparoscopic sacrocolpopexy (LSC). In all cases monofilament suture was used to secure polypropylene mesh to the vagina. Those women with a uterus who underwent RALSC all had a supracervical hysterectomy (SCH) and intracorporeal suturing of mesh to the vagina and sacrum. Those who underwent LSC had a total vaginal hysterectomy (TVH) with transvaginal dissection of vesicovaginal and rectovaginal spaces. Mesh was then secured to the walls of the vagina either transvaginally or laparoscopically after vaginal cuff closure and sacral attachment was performed laparoscopically using tacks. Chi squared, Fischer's exact, and t tests were used to explore relationships between mesh erosion and risk factors. Variables with P < 0.10 were entered into a multivariable regression model to identify odds of mesh erosion with 95% confidence intervals (OR; 95% CI).
A total of 196 women underwent MISC and 96% (62 RALSC and 126 LSC) had sufficient data for follow-up. The mean age of the 188 women was 61 ± 9 years and median prolapse stage of 3. Median follow up was 20 (3–124) weeks in the RALSC compared to 14 (2–171) weeks for LSC group, (P = 0.280). A total of 34% (21) in the RALSC and 44% (57) in the LSC group had concomitant hysterectomy. Of those who had a TVH, 29 had the mesh attached to the vagina transvaginally while 28 were attached laparoscopically. The overall mesh erosion rate for MISC was 10% (19/188). In the RALSC group, mesh erosion rates were 5% in both the post-hysterectomy and SCH groups (P = 0.984). In the LSC group, mesh erosions in the post-hysterectomy group were 4% while those in the concomitant TVH group were 23% (P = 0.003) (Figure 1.) There were no differences in age, parity, weight, preoperative prolapse, duration of surgery, postoperative anemia, or predisposing medical conditions (diabetes, smoking, hormone use) between subjects who did and did not develop erosion. Multivariable regression models included posterior colporrhaphy, TVH, and laparoscopic placement of mesh. Only TVH remained a significant risk factor for mesh erosion compared to post hysterectomy (5.67; 1.88–17.10). There was no difference in mesh erosion between SCH and post hysterectomy (0.99; 0.11–9.03). A trend towards higher mesh erosion with laparoscopic placement of mesh after TVH compared to vaginal placement was seen (2.96; 0.79–11.09).
TVH at the time of MISC increases the likelihood of developing mesh erosion. Rates of mesh erosion in the SCH group were similar to the post-hysterectomy groups.