Following a series of high profile cases showing the potentially catastrophic consequences of vaginal mesh insertion for stress urinary incontinence (SUI) recommendations have been made to halt further insertions. The National Institute of Health & Clinical Excellence (NICE) have updated their guidance to this effect. Removal of meshes is performed in specialist salvage centres such as ours. It is not always clear why some patients have problems with their meshes and the range of presenting complaints is varied. This study outlines the following: presenting complaint of patients attending for vaginal mesh salvage surgery; it then goes on to highlight the microbiology findings of meshes removed following complications and the possible links to presenting complaint.

Review of prospectively maintained database for patients referred with complications related to mesh insertion between 2012-2018, date of surgery, type of repair, microbiology (microscopy and culture) and histology findings of mesh.

In total, 58 patients were identified, 53 underwent vaginal mesh removal procedures.  From 2017 the removed mesh (n=23) began to be routinely sent for microscopy, culture and sensitivities (MC&S). Perioperative IV antibiotics given and Betadine applied to the operation field.  Of the specimens (n=23) sent; 10 were negative and 13 were positive on at least one category in MC&S.  The following results were identified: 5 showed Polymorphs +/- on gram stain, 1 showed Gram +ve bacilli, 3 grew bacteria on primary culture: Strep. Anginosus, Ent. faecalis, Beta Haem Strep gp B & Pseudo. aeruginosa (same culture). A further 7 samples grew bacteria from the broth only Diphtheroid bacilli & Mixed Anaerobes, E coli, Ent. faecalis, Lactobacillus sp, Propionibact. Avidum, Strep. milleri & Enteroba. Hormaechei, Strep. parasanguinis & Candida glabrata & Mixed Anaerobes. 
The presenting complaints of the 23 patients were varied and the results are as follows: Mixed incontinence (6), Recurrent UTIs (5), Vaginal erosion (4), Voiding dysfunction (3), Dyspareunia (2), Vaginal discharge (1), Dysuria (1) and CPP (1). Of the 23 sent for culture the complaints were as following Of the cultures that tested positive on culture the presenting complaints were varied. Of the 13 positive results, 5 presented with mixed incontinence, 4 with recurrent UTIs, and 1 each with dyspareunia, dysuria, vaginal erosion and voiding dysfunction
The 5 mixed incontinence samples were positive for Polymorphs only (2), Primary culture (1 – Ent faecalis), Broth only (2).  The recurrent UTIs samples had Positive culture (1) and Broth only positive (4). 
Similarly the meshes were sent for histology, these findings showed a majority of cases mild to moderate chronic inflammation and foreign body giant cell reaction.

There is a possible risk that such could be due to contamination as the surgery is not “clean”. Equally it could be due to chronic, low-grade deep infection within the synthetic mesh. Measures to explore this further could include sending vaginal and urine samples sent for MC&S in addition to the mesh removed simultaneity.  Doing such would potentially assist in the management strategies for future vaginal mesh salvage cases.
It is of interest that 4 out of 5 of the patients presenting with recurrent UTIs showed positive findings on MC&S. This may be of relevance to future patients and may be an indication for collecting urine for microscopy and impacting on treatment options.

It is still not clear from this study why some meshes become colonised by bacteria and others do not. It is not immediately apparent if the presence of colonisation leads to mesh complications. As more data becomes available, both in terms of sending samples routinely for MC&S and potentially taking swabs/MSU for MC&S we may learn more about the types of bacteria present and their impact on complications.