Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
One of the main complications caused by the use of surgical techniques for transvaginal correction of pelvic organ prolapse is extrusion.
We present a 73-year-old woman, with a story of abdominal hysterectomy and cystocele corrected by Prolift mesh, with a late recurrence treated by partial colpocleisis. After 4 years, the patient was referred to our hospital because of an intravesical and vagina extrusion of the mesh, which caused vesicovaginal fistula and stress urinary incontinence (intrinsic sphincter deficiency). Furthermore, she suffered from an intense pain in the hypogastrium (9 out of 10 points in the Visual Analogue Scale Pain, VASP).
We performed a cystoscopy and a pelvic MRI, allowing the diagnosis of an extrusion of a calcified mesh in vagina and bladder (vesicovaginal fistula).
We removed the calcifications as well as the extruded mesh by an incision in the previous partial colpocleisis. We located and closed the fistula in 3 layers, creating a Martius flap transposed to the vagina. Finally, the stress urinary incontinence was corrected by means of an adjustable autologous sling with the abdominal rectus fascia.
A cystoscopy was performed, which showed an extrusion at the bladder neck level with associated calcifications. First of all, we catheterized both ureters. An incision was made on the colpocleisis septum to allow access. Subsequently, an incision was made on the area of the extruded mesh and by making a dissection with scissors, the mesh and the adhered calcifications were removed. A 2 cm vesicovaginal fistula was then visualized, which was closed in 2 layers. We created a right Martius flap and then, we transposed it to the vagina.
We continued the procedure with an incision in the hypogastric midline, making a
dissection of the rectus abdominis fascia, and then we obtained a sling from that fascia (6 x 2 cm).
To continue with, we created an adjustable sling using the Remeex system, which consists in replacing the original mesh by the autologous fascia of the patient.
Subsequently, we made a mid suburethral incision and a periurethral dissection.
We fixed the new autologous sling in the middle urethra, following the usual technique procedure.
Finally, we fixed the Martius flap to protect the area of the fistula. After that, we closed the vagina and then we did the vaginal tamponade.
The patient presented a favorable postoperative period. Currently, the patient is without pain, without stress urinary incontinence or voiding and storage symptoms.
The extrusion and calcification of the mesh to correct the prolapse of the pelvic organs is a complication that causes a great impact on the quality life of patients. The treatment of this complication involves the removal of the mesh and the treatment of the associated complications, which can be solved in the same surgical act. The use of an adjustable Remeex® type system with replacement of the synthetic mesh by autologous tissue can be a feasible solution for a complex mesh complication.