Tips/Tricks Presentations: AUGS Abstracts: 2005 26th Annual Scientific Meeting of The American Urogynecologic Society
The development of a safe, readily available, and inexpensive technique to better expose the surgical field, and aid in intraoperative teaching during vaginal surgery for eroded mesh.
The incorporation of various synthetic and natural mesh materials into repairs for pelvic organ prolapse has become commonplace. Bladder, bowel, urethral, and vaginal erosions are all reported. Transvaginal excision of eroded vaginal mesh and reapproximation of noninfected tissues is emerging as the treatment of choice if conservative measures fail. This approach is complicated by a small surgical field, poor exposure, and poor visualization of tissue planes. Cases involving the vaginal apex can be especially challenging. In some cases, the margins of the mesh and anchoring sutures cannot be adequately exposed. We have found cystoscopic or hysteroscopic video equipment extremely valuable in the intraoperative management of these cases. A 12 or 30 degree cystoscope with a 17Fr. sheath (or hysteroscope with a 5 mm sheath), standard endoscopic light source, and standard video equipment are used. Irrigation is accomplished through the scope. The forward oblique angle of the lens aids in exposure without obstructing the surgical field. The light source provides directed, high intensity illumination which is often difficult with overhead lights. Standard surgical instruments are used for the dissection and excision. Overhead video monitors and digital imaging technology allow for observation by the entire surgical team and for photo documentation of the case. This technique does not involve any novel surgical equipment.
We have successfully utilized this approach in the management of apical mesh erosion following colpopexy and TVT, and in the complete excision of eroded mesh used for anterior repairs. In the latter cases we have also found the technique useful for the identification and removal of permanent suture materials. Improved exposure with the use of endoscopy simplifies and expedites the operation. It minimizes dissection around the erosion. Injury to adjacent structures can also more easily be avoided. Additionally, we are able to photograph the procedure, and provide a better learning experience for residents. The use of video monitors allows the entire surgical team, residents, and students to visualize the operation.
Endoscopy is a valuable tool in the management of vaginal mesh erosion. It facilitates exposure and removal of the eroded mesh, provides a learning tool for surgical assistants and residents, and allows the interested patient to see photographs of the eroded/excised mesh. We now routinely have endoscopic video equipment available for all cases of mesh erosion.