Mesh has been used to treat pelvic organ prolapse since the year 2000 and has been used worldwide owing to its good results. Around 2010, transvaginal mesh was popular. However, the United States Food and Drug Administration issued a warning regarding mesh-related complications and banned mesh in 2019. Tension free vaginal mesh (TVM ) has been used in Japan since 2005. We have treated more than 5,000 cases in our facility; however, we rarely have trouble with mesh-related complications. Why are there few problems in our facility? This is the first study to examine mesh-related complications at our facility. This study is divided into two parts: mesh exposure in a patient who underwent TVM surgery at our facility and was followed up for 5 years; and mesh removal in our facility. Here we will introduce the use of an otolaryngology suction tube to remove the mesh.

In the first part of the study, 582 patients who underwent TVM surgery between March 2010 and December 2013 and were followed up for 5 years were included.
In the second part of the study, 34 patients who underwent mesh removal surgery between March 2015 and December 2019 were included, and the causes and period until mesh removal were studied. The study was approved by our facility’s ethics committee (No.77). In the removal method, the mesh is fixed with a non-absorbent suture and then an otolaryngology suction tube is used pulling upon it. The use of scalpels and scissors is avoided whenever possible. The mesh is cut after sufficient separation is achieved. The tissue side is then separated by rubbing the mesh with the otolaryngology suction tube.

In the first part of the study, the average patient age was 66.7 years, and the mesh insertion sites included 287 in the anterior wall, 47 in the posterior wall, and 248 in both walls. The frequency of mesh exposure was 2%, and mesh removal was performed in 5 cases of the vaginal wall and 1 case in the bladder. In the second part of the study, the average patient age was 73.7 years and mean body mass index was 24.3. Sixteen patients underwent TVM surgery at our facility, while 18 patients underwent transvaginal mesh surgery at other facilities. We removed the mesh due to pain in 9 cases, bleeding in 6 cases, urinary dysfunction in 5 cases, no symptoms in 12 cases, and discomfort in 2 cases.
Nine patients underwent concomitant surgery (TVM, bladder hydrodistention, laparoscopic sacrocolpopexy, etc.). Mesh was exposed in 26 of 34 cases. The mesh insertion site of the previous mesh surgery included 9 cases in the anterior wall, 5 in the posterior wall, and 8 in both walls (2 in uterus and 6 after total hysterectomy). There were 10 cases of unknown TVM and 2 of mesh surgery other than TVM. The meshes were inserted between 2008 and August 13, 2019. The time to mesh removal or cutting ranged from 40 days to 10 years (=3784 days) and was less than 1 year in 6 cases.
The meshes were removed in 10 cases of posterior wall, 17 of anterior wall, 3 of mesh arm cutting, and 4 of other. The mean operation time for mesh removal was 30 minutes, while the mean blood loss was 25 g.

According to one study, the incidence of mesh exposure in 2007 was reportedly 0–33%. Regarding polypropylene mesh (PP) erosion, several studies reported an incidence of 11.3–20%. Another study reported mesh exposure rate of a 15.8% in cases of TVM. The current study reports a low mesh exposure rate of 2% over 5 years. We believe that mesh contracture causes exposure; therefore, we pay careful attention when performing TVM and believe that this led to our good results. Many cases of mesh removal from both walls occurred after hysterectomy. Therefore, mesh insertion requires caution in cases of total hysterectomy. A previous study reported that mesh exposure occurs frequently within 1 year after placement. However, in this study, long-term follow-up was required because some patients underwent its placement more than 10 years prior, although the duration of exposure is unknown. Vaginal atrophy progressing over time appears to lead to exposure. Mesh removal using an otolaryngology suction tube took an average of 30 minutes. The surgical field is clear because the operation can be performed with aspiration of bleeding and piece of tissue. Because the otolaryngology suction tube is made of metal and has a tapered tip, the tube does not deform even when rubbed with force and we can perform fine work. Rubbing off the mesh can minimize the damage to the surrounding tissues and avoid injury. This technique is inexpensive because the equipment is reused.

Here we described mesh exposure and removal in our facility. Although we report much lower exposure rates than other reports, our findings suggest a long-term exposure risk.

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