Mesh Sling Salvage Surgery Results Mixed
BEIJING—Even if salvage operations ease complications from unsuccessful mesh sling surgery, patients often are in worse condition than before their original surgery, according to a urologist.
Jerry Blaivas, MD, of the Weill Cornell Medical College in New York, reviewed 47 cases in which he performed corrective surgery after at least one prior surgical attempt to correct mesh sling complications. The cases were from 1998 to 2011. Seventy-two percent of the operations were successful, Dr. Blaivas noted, but the outcomes were frequently suboptimal, even in cases of success and with careful technique such as removing as much of the mesh as possible and repairing the anatomic defect.
“The ‘successes' were only relative for many patients—that is, they were better than were before their salvage surgery, but most were much worse than before their original sling surgery,” Dr. Blaivas told Renal & Urology News. “It was a shortcoming of our study to not ask the patients how their final status compared to how they were originally. “
Dr. Blaivas presented the case series at the International Continence Society's 2012 annual meeting to highlight the difficulties urologists can expect when performing such salvage operations. The women's mean age was 60 years (range 35-83 years) and the average time from sling surgery to diagnosis of a complication was about two years (range one month-eight years). They had a mean of 1.9 prior surgeries to correct the sling complication. In 76.5% of cases the original sling was an Amid type 1 (monofilament and macroporous) and 87% were placed in the retropubic position.
The women presented to him with conditions ranging from urethra-vaginal fistulas and erosions into the bladder or urethra to overactive bladder, stress incontinence, pelvic pain/dysuria and vaginal extrusion. He proceeded with sling excision with or without urethrolysis in 16 cases, sling excision with urethral reconstruction with or without autologous fascial sling and Martius flap in 14, sling incision in 10, and uretero-neocystotomy or cystotomy with or without partial cystectomy in the remaining seven cases.
The mean follow-up time after salvage surgery was 3.3 years. Thirty-four of the salvage surgeries (72.4%) were a success. Four were outright failures. The remaining patients had a successful second operation: three had augmentation cystoplasty, one had an autologous sling, and one had a continent urinary diversion with cystectomy.
Even in “successful” post-salvage surgery, however, many women retained their presenting symptoms. For example, both women presenting with ureteral injury still had their presenting pain symptoms at follow-up; in fact, only 50% of patients with pain were improved after surgery. However a successful outcome was achieved in 93% of those with a pre-operative fistula, 91% of those with bladder or urethral erosion, 100%% of those with voiding dysfunction, and 86%% presenting with discharge or hematuria. “Nevertheless, the failure rate is still too high,” Dr. Blaivas concluded.
Besides striving to remove as much of the mesh as possible and repairing the anatomic defect, he advised meeting attendees to use biologic tissue rather than another synthetic if another sling is needed, and place a Martius flap between the reconstructed urethra and the new sling.