Sacrocolpopexy is an effective treatment for advanced pelvic organ prolapse with predictable anatomic and functional outcomes. We describe a rare complication of mesh erosion into the rectum and subsequent multidisciplinary management. Multidisciplinary, experienced subspecialty care can address difficult complications of pelvic floor surgery with a minimally invasive approach.
Surgical correction of pelvic organ prolapse increasingly utilizes artificial materials. Mesh erosion/extrusion is a well-recognized complication of mesh sacrocolpopexy. A 2004 review of abdominal sacrocolpopexy identified a median short-term mesh erosion rate of 3.4% (range, 0–5%). More recent data suggest that the rate could be higher, particularly with concurrent hysterectomy. Correction of mesh complications can be complex and associated with poor functional outcomes. We describe features of a late presentation of mesh erosion into the rectum, and details of management with a minimally invasive approach.
Case Report
A 51-year-old secundiparous woman underwent total abdominal hysterectomy with Burch urethropexy in 1998. She subsequently experienced vaginal vault prolapse with urinary retention and recurrent urinary tract infections. In 2000, she was treated with Mersilene mesh sacrocolpopexy and takedown of the urethropexy by laparotomy.
In September 2007, at the time of a screening colonoscopy, the patient was found to have inflammatory changes that were associated with an exophytic lesion that was identified in the rectum. Other than constipation, she was asymptomatic at this time. Biopsy examinations of the area showed chronic nonspecific proctitis. Her condition subsequently was evaluated by a gynecologist who noted erosion of mesh material into the rectum and vaginal foreshortening. The patient was referred to a colorectal surgeon who, on office sigmoidoscopy, identified Mersilene mesh and suture material extruding into the anterior rectum approximately 8-10 cm from the anal verge ( Figure 1 ). The patient was next referred to a female pelvic medicine and reconstructive surgery (FPMRS) specialist who identified stage I vaginal support and confirmed the finding of rectal mesh that was associated with the previous sacrocolpopexy. No mesh was seen within the vagina, but tenderness was elicited at the vaginal apex. The total vaginal length measured 6 cm. The recommendation of the colorectal and FPMRS surgeons was to remove the mesh.
The colorectal and FPMRS surgeons in a combined case performed laparoscopic-assisted excision of mesh ( Figure 2 ). After laparoscopic excision of the mesh from 3 cm below the sacral promontory to the rectal defect, a minilaparotomy was performed to repair the rectal defect ( Figure 3 ). Mesh attachment to the vagina was primarily to the posterior wall, with little mesh attached to the anterior vaginal wall. The attachments of the mesh to the rectum and vagina were taken down, which created a 2- to 3-cm rectal defect with the mesh removed through the rectal defect through the anus. A minilaparotomy was next performed to close the rectal defect adequately. Rectal integrity was confirmed with air insufflation. The postoperative course was complicated by wound seroma that was opened secondarily and treated with wet-to-dry dressings. After 9 months, the patient had recovered fully, with no new pelvic floor or bowel-related symptoms reported.
