Data on perioperative complications are presented as frequencies (%). A risk analysis of major complications was performed using a backwards multivariable logistic regression model assessing the impact of age, parity, weight, perioperative antibiotics, prior pelvic floor surgery, prior hysterectomy, and concurrent surgical procedures. Results from the risk analysis are presented as odds ratios (ORs) with 95% confidence intervals (CIs). All analyses were performed with Statistica software, version 7 (Statistica, Tulsa, OK).
The study was approved by the Stockholm Regional Board of Ethics at Karolinska Institutet, Stockholm, Sweden. The transvaginal mesh manufacturing company had no influence over study aim, study design, execution of the study, or analysis and interpretation of data. The corresponding author performed all analyses of the data and had full control and access to all information regarding the manuscript content, drafted the paper, and had the final responsibility for the decision to submit for publication.
Patient characteristics and surgical data are presented in Table 1. Anterior repair was performed in 106 of the 248 patients (43%), posterior repair in 71 patients (29%), combined anterior and posterior repair in 20 patients (8%), and total repair in 51 patients (21%) (Table 1). Concomitant surgical procedures were performed in 58 patients (24%): 21 vaginal hysterectomies, 27 posterior colporrhaphies, seven tension-free vaginal tape (TVT) or transobturator tension-free tape procedures, five sacrospinal fixations, three vaginal wall repairs using other mesh, one posterior intravaginal sling plasty, one vaginal enterocele obliteration, one bilateral salpingo-oophorectomy, and two cervix amputations.
General anesthesia was used in 49 patients, spinal anesthesia in 162 patients, epidural in 11 patients, combined spinal and epidural in 12 patients, and local anesthesia alone in three patients (information on anesthesia is missing for 11 patients). Perioperative antibiotics was administered in 235 subjects (95%), four patients did not receive any antibiotics, and information was missing in the remaining nine patients.
The overall rate of serious complications was 4.4% (95% CI 2.5–7.8) (11 of 248 patients) and was dominated by visceral injury (Table 2). Minor complications occurred in 14.5% (95% CI 10.7–19.4) (n=36) and were dominated by urinary tract infections, urinary retention, and postoperative fever (Table 2). Detailed complication rates and perioperative morbidity for the various surgical procedures are shown in Table 2.
The multivariable risk analysis showed that concurrent pelvic floor surgery was associated with an increased risk for minor complications (OR 2.8, 95% CI 1.1–6.9) (Table 3). We found no other predictors of outcomes when assessing the association with age (by year), parity (by number of childbirths), weight (by kilograms), previous pelvic floor surgery, previous hysterectomy, or concurrent hysterectomy (Table 3).
When evaluating safety aspects of biomaterial implants in pelvic floor surgery, emphasis is usually placed on the morbidity associated with specific biomaterials,15,16 with relatively little attention paid to the actual surgical techniques. The present study focuses on immediate morbidity caused by the surgical technique rather than mid- to long-term complications such as rejection, erosion, and infections, typically ascribed to the biomaterials themselves.
We found that serious complications occurred in 4.4% of our cases using the described transvaginal mesh system. Although we consider the rate of serious complications relatively low, particular care should be taken to detect visceral injury at the time of surgery, considering that visceral injury accounted for 10 of the 11 cases of serious complications. A similar rate of serious intraoperative complications (3.6%) was reported in a recent series of 148 patients using an alternative transvaginal mesh system.17 Even though the transvaginal mesh systems are diverse and data not completely comparable because of the inherent differences in surgical techniques, visceral injury constituted the most common serious complication also in this study, occurring in 4 of 148 (2.7%) cases.17
Close to 15% of our patients experienced what we characterized as minor complications. Although not life threatening, such complications may have considerable impact on quality of life and daily function. Prospective studies extending beyond the operative hospital stay are therefore needed to clarify how minor complications attributed to the surgical procedure, such as groin pain, buttock pain, defecation difficulties, urinary urgencies, and bladder-emptying difficulties, progress over time. Not surprisingly, a transvaginal mesh procedure performed in concurrence with other pelvic floor surgery was associated with an increased risk for minor complications compared with isolated transvaginal mesh procedures. We found no other predictors of major or minor morbidity in patient characteristics or surgical history.
Compared with posterior repair, anterior repair was associated with a longer operating time, greater blood loss, and more frequent complications despite similar patient characteristics. This may be attributed to the higher proportion of patients undergoing repeat surgery of the anterior compartment when compared with the posterior compartment, and subsequently, more difficult dissections. However, this may also reflect actual differences in surgical anatomy. Anterior vaginal dissections may be associated with excessive bleeding, requiring heightened attention due to injury to vascular structures such as the veins of Santorini. Also, the passage of four supportive arms of the anterior mesh, compared with two in the posterior procedure, could negatively influence surgical characteristics. The prolonged length of stay for patients after an anterior, compared with a posterior, repair may be associated with the higher complication rate associated with anterior transvaginal mesh. The overall length of stay in the present study was similar to what previously has been reported from Sweden in recent years when evaluating pelvic reconstructive surgery, both with and without mesh.18,19
When interpreting our data, a number of study traits needs consideration. First, the majority of procedures were performed because of prolapse recurrence in a previously operated vaginal compartment. This may cause subsequent difficulties with scar tissue and fibrosis in the surgical area and may have affected our complication rate negatively. Second, although the participating gynecologists were all experienced pelvic floor surgeons, this series represents the first experience with a new surgical technique. It is possible that the complication rate may decrease because many procedures were performed in the beginning of the learning curve. Finally, a surgical procedure may be universally accepted when the magnitude of its benefits outweighs the risks. To decide whether transvaginal mesh procedures are beneficial in comparison with traditional suture techniques, prospective comparative studies are necessary.
Our study is strengthened by the large scale multicenter design, the standardized surgical procedure, and the pretrial hands-on training required for all participating surgeons. In this first prospective description of surgical complications associated with the transvaginal mesh, we decided to prioritize the ability to generalize our findings to a broad population through the wide range of patients included. We recognize that our sample size may not suffice for detection of rare surgical complications. This is, however, difficult to achieve in a clinical setting in a reasonable amount of time, and future studies using a retrospective, or register-based, design may comprise larger study populations able to describe also infrequent complications. A further limitation of the present study is the possibility of selection bias, caused by the open and unrestricted inclusion, influencing our results. Considering the large numbers of previous pelvic floor surgeries performed in this group of patients and the fact that the majority of transvaginal mesh operations were performed because of recurrences, one may argue that, if any, selection was toward more complicated patients and subsequently more difficult procedures.
Much of the current knowledge of biomaterial in vivo characteristics in pelvic floor surgery derive from research on suburethral sling procedures, such as the TVT.18,19 It is, however, important to consider the different anatomical conditions associated with pelvic organ prolapse surgery. Compared with suburethral tapes, biomaterials used at pelvic organ prolapse repair increase the biomaterial load considerably because of the increased size of the mesh. This may increase the risk for adverse tissue reactions and biomaterial-associated complications. Although the polypropylene compound used for TVT and transvaginal mesh is identical, other characteristics, such as elasticity and pore size, differ. One should, therefore, not assume that the biomaterial properties are the same for the two procedures, and results from incontinence surgery may not be directly applicable to pelvic organ prolapse surgery. Caution is advised until large-scale long-term prospective safety studies describing biocompatibility are available.
1. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6.
2. Clark AL, Gregory T, Smith VJ, Edwards R. Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2003;189:1261–7.
3. Emge L, Durfee R. Pelvic organ prolapse: four thousand years of treatment. Clin Obstet Gynecol 1966;9:997–1032.
4. Parker MC, Phillips RK. Repair of rectocoele using Marlex mesh. Ann Roy Coll Surg Eng 1993;75:193–4.
5. Watson SJ, Loder PB, Halligan S, Bartram CI, Kamm MA, Phillips RK. Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. J Am Coll Surg 1996;183:257–61.
6. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced with Marlex mesh for the treatment of cystoceles. Int Urogynecol J Pelvic Floor Dysfunct 1998;9:200–4.
7. Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357–64.
8. Clemons JL, Myers DL, Aguilar VC, Arya LA. Vaginal paravaginal repair with an AlloDerm graft. Am J Obstet Gynecol 2003;189:1612–8.
9. Porter WE, Steele A, Walsh P, Kohli N, Karram MM. The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol 1999;181:1353–9.
10. Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299–306.
11. Sloots CE, Meulen AJ, Felt-Bersma RJ. Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time. Int J Colorect Dis 2003;18:342–8.
12. Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, Sand PK. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 2005;105:314–8.
13. Walters MD. The use and misuse of prosthetic materials in reconstructive pelvic surgery: does the evidence support our surgical practice? Int Urogynecol J Pelvic Floor Dysfunct 2003;14:365–6.
14. Debodinance P, Berrocal J, Clave H, Cosson M, Garbin O, Jacquetin B, et al. Changing attitudes on the surgical treatment of urogenital prolapse: birth of the tension-free vaginal mesh [in French]. J Gynecol Obstet Biol Reprod 2004;33:577–88.
15. de Tayrac R, Gervaise A, Chauveaud A, Fernandez H. Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse. J Reprod Med 2005;50:75–80.
16. Collinet P, Belot F, Debodinance P, Ha Duc E, Lucot J, Cosson M. Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:315–20.
17. de Tayrac R, Devoldere G, Renaudie J, Villard P, Guilbaud O, Eglin G. Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study. Int Urogynecol J Pelvic Floor Dysfunct 2006. Epub ahead of print.
18. Mellgren A, Anzen B, Nilsson B, Johansson C, Dolk A, Gillgren P, et al. Results of rectocele repair: a prospective study. Dis Colon Rectum 1995;38:7–13.
19. Altman D, Zetterström J, López A, Anzén B, Falconer C, Hjern F, et al. Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study. Dis Colon Rectum 2005;48:1233–42.
20. Falconer C, Soderberg M, Blomgren B, Ulmsten U. Influence of different sling materials on connective tissue metabolism in stress urinary incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 2001;12 suppl:S19–23.
21. Dietz HP, Vancaillie P, Svehla M, Walsh W, Steensma AB, Vancaillie TG. Mechanical properties of urogynecologic implant materials. Int Urogynecol J Pelvic Floor Dysfunct 2003;14;4:239–43.
This study was made possible through the cooperation and collective efforts of the Nordic Transvaginal Mesh Group:
© 2007 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
- Sweden: Daniel Altman, Stockholm; Bo Anzén, Stockholm; Lena Clementsson, Kristiansstad; Christian Falconer, Stockholm; Folke Flam, Stockholm; Jonas Gunnarsson, Göteborg; Björn Holm, örebro; Kenneth Krohn, Norrköping; Gregor Larson, Västerås; P-G Larsson, Skövde; Paula Löwenadler, Ystad; Mazoumeh Rezapour, Uppsala; Gunilla Tegerstedt, Stockholm; Vasiliki Tsaknakis, Halmstad; and Jan Zetterström, Stockholm.
- Denmark: Susanne Axelsen, Skejby; Karl Möller Bek, Skejby; and Jens Prien Larsen, Nyköbing Falster.
- Finland: Pentti Heinonen, Tampere; Reijo Hiltunen, Seinajoki; Penti Kiilholma, Turku; Teuvo Takala, Lahti; Kirsi Rinne, Koupio; Hans Unnerus, Lojo; and Tapio Väyrynen, Jorvi.
- Norway: Marie Ellstrøm Engh, Aakershus; Nils Eriksson, St. Olav; Kolbjörn Kasin, Kongsberg; and Sigurd Kulseng Hansen, Asker Baerum.