Surrounding tissue sparing technique for vaginal mesh explantation

Martinez-Garcia R1, Valls-Gonzalez L1, Sanchez Cano E1, Medina Gonzalez M1, Lloret Dura M1, Tonazzi Zorrilla R1, Alonso Gracia N1

Research Type

Clinical

Abstract Category

Female Stress Urinary Incontinence (SUI)

PRIZE AWARD: Best Video Abstract
Abstract 712
Video Session 3 - Male / Wild Card
Scientific Podium Video Session 35
Friday 6th September 2019
15:00 - 15:09
Hall G2
Pelvic Organ Prolapse New Instrumentation Surgery Stress Urinary Incontinence
1.University Clinic Hospital. University of Valencia. Spain
Presenter
R

Roberto Martinez-Garcia

Links

Abstract

Introduction
Synthetic vaginal meshes are a current issue for safety, legal and social reasons. FDA notifications were based on the concept of “irreversibility” or “great difficulty” in reversing the secondary effects, mainly pain, even after removing the mesh.
Many publications are describing the consequences of vaginal meshes and how to manage residual pain, but few have tried to improve the surgical explant technique.
What do we know about the explant technique of vaginal meshes?
It is believed that resection of large portions of mesh (such as that of several compartments) leads to greater morbidity such as increased bleeding. However, not explanting the entire mesh or leaving some synthetic material often leads to the persistence of the problem and new reinterventions. Some women required two to three additional surgeries to resolve symptoms. It is important, then, to remove the mesh completely in the first intervention to avoid recurring pain. Not doing it is nowadays considered a complication by many authors.
With conventional techniques, the more fibrosis there is (due to the existence of folded or retracted mesh areas), the greater the amount of surrounding tissue we need to remove. That can produce an additional damage to the one that already was produced by the mesh.
The existence of vascular, nervous or neighbouring organs in contact with the scar pose a huge risk of injury in explant surgery. Li et al.[1] observed a significant correlation of the presence of adipose tissue surrounding the explanted mesh with pelvic pain. This suggests that removing the mesh including the surrounding fat (and neighbouring tissue) is associated with pain.
That's probably why some of these complications are considered irreversible and crippling. Until now it has been considered a "necessary" damage to remove the mesh and therefore intrinsic to the mesh itself. But, is it really true?
Design
An instructional video with a structure that shows all the steps and tricks necessary for removing a vaginal mesh.
It is applicable to both prolapse and transobturator or retropubic urethro-suspension meshes.
Results
A uretrosuspension tape excision technique is showed. We present a structured surgical technique of mesh explant with the example of a transobturator uretrosuspension tape, because it is the simplest technique.
It is a surrounding tissue sparing technique, it shows how to avoid damage during the explant.
It shows the advantage of pulsed radiofrequency electrosurgery that only cuts organic tissue, not the material of the synthetic mesh. This allows cutting very close to the mesh (sliding the cutting edge over the mesh).
In areas not accessible to the electrocautery, the use of a gauze over the glove increases the adherence and allows to remove less tissue.
It also shows minimal bleeding and reduced chance of neighbouring structure injury.
The complete explant of the non-intramuscular area of the mesh (without residues of synthetic material) is easy achieved.
Conclusion
We hope that this surrounding tissue sparing technique, with the use of adequate instruments and tricks, will reduce the morbidity of surgeries for the explant of synthetic meshes.
The use of a radiofrequency pulse electrocautery that cuts at low temperature is important. It allows directly cutting the fibrous scar next to the mesh scarcely damaging the surrounding tissues with relative ease as it does not cut the mesh material.
References
  1. Li L, Wang X, Park JY, Chen H, Wang Y, Zheng W. Pathological findings in explanted vaginal mesh. Hum Pathol. 2017;69:46–54.
Disclosures
<span class="text-strong">Funding</span> NOT funding or grant <span class="text-strong">Clinical Trial</span> No <span class="text-strong">Subjects</span> Human <span class="text-strong">Ethics not Req'd</span> Is a video about surgical skill <span class="text-strong">Helsinki</span> Yes <span class="text-strong">Informed Consent</span> Yes