Vaginal mesh kits are increasingly used in vaginal prolapse repair. Mesh erosion, infection, and pain may necessitate removal, which can lead to urinary tract injury. We describe 2 cases of ureteral injury at the time of mesh excision. Surgeons must recognize the possibility of ureteral injury and treatment modalities available.
Vaginal mesh kits are used frequently for repair of vaginal prolapse. Although many procedures are successful, some complications have occurred. Some complications are amenable to conservative management, but a subset requires surgical mesh removal. The substantial fibrosis induced by polypropylene mesh, the depth of the surgical dissection plane, and the proximity of the anterior mesh and anchoring arms all predispose the ureter to injury during mesh removal. We review 2 cases of ureteral injury that occurred during mesh excision.
Case Reports
Case 1
A 46 year old woman had dyspareunia, recurrent prolapse, and urge incontinence after undergoing placement of a total PROLIFT kit (Ethicon Inc, Somerville, NJ) and synthetic midurethral sling (GYNECARE TVT, Ethicon Inc). Pelvic examination elicited pain at the distal right mesh arm and revealed anterior and apical prolapse. Operatively, the anterior dissection was carried toward the right, and mesh body and arms were excised. The ureter was inadvertently transected during the dissection. A left ureteral stent was placed and inadvertent injury averted only after a transvaginal ureterolysis.
It is unclear whether the apical prolapse or individual anatomical variation contributed to these findings ( Figure ). The ureteral injury was treated with a right ureteroneocystostomy. Six weeks postoperatively, computed tomography urography showed no extravasation of contrast or evidence of stricture. Her presenting pain symptoms resolved, but urinary retention developed, requiring self-catheterization. She subsequently underwent implantation of an InterStim Therapy device (Medtronic, Minneapolis, MN), with resumption of voiding.
Case 2
A 75 year old woman had urinary retention and pain after a total vaginal mesh kit placement (Apogee and Perigee; American Medical Systems, Minneapolis, MN). The pelvic pain had developed immediately after surgery and proved unresponsive to high-dose narcotics and isolated mesh lysis. Physical examination revealed a shortened vagina with palpably painful, taught mesh arms, without visible erosion. She underwent transvaginal excision of anterior and posterior vaginal mesh 9 months after the kit was originally implanted. Three months after the mesh excision procedure, she reported urinary leakage; stress incontinence and a ureterovaginal fistula were diagnosed. The stress incontinence was treated with a midurethral sling. Despite prolonged use of a ureteral stent, a persistent ureterovaginal fistula was noted 10 weeks postoperatively, which was managed with a left ureteroneocystostomy. At the time of last follow-up, she was successfully tapering off pain medications and reported no urinary incontinence.
Comment
Vaginal mesh kits are being increasingly used in vaginal prolapse repair because of their ease of use and a theoretically decreased risk of prolapse recurrence. However, the literature suggests that 4.4-14.5% of patients have significant morbidity after mesh kit procedures, including mesh erosion, infection, pain, incontinence, and recurrence of prolapse. In 2011, the US Food and Drug Administration issued a public health notification that complications after vaginal mesh are not rare and that thorough counseling regarding risks and benefits should be undertaken before using such kits. Johnson and Johnson Medical Ltd (New Brunswick, NJ) have since discontinued their vaginal mesh prolapse and minimidurethral sling product line. Complications from mesh may be related to mesh contracture, poor surgical technique, implanter inexperience, inappropriate tensioning during the index procedure, variable individual responses to implanted mesh, or a combination of factors.
The significant inflammation from host incorporation, relatively blind placement, and the proximity of urinary structures to supporting anchors predisposes the ureter to injury during mesh placement and removal. The posterior trocar passes within a mean of 2.5 cm from the ureter as it transverses the pararectal space. Furthermore, prolapse may alter ureter position and predispose it to injury (eg, case 1 with significant apical prolapse).
We now routinely place stents during mesh excision to minimize the risk of injury to the urinary tract. Although the crude rate of ureteral injury during gynecologic surgery is 16-29 per 1000 surgeries, the risk during mesh excision is unknown. Also, it is unclear whether the current recommendation to place transvaginal mesh at a deeper dissection depth will affect rates of injury to the urinary tract.
Managing complications after vaginal mesh placement should be tailored to the patient’s presenting symptoms. Conservative approaches such as physical therapy and corticosteroid injections should be considered for patients with minor symptoms. Patients with minor mesh exposure or isolated pain symptoms who desire surgery can instead be treated with less invasive procedures to remove the offending exposed mesh or with transection or removal of the arm causing symptoms. However, patients with diffuse pain symptoms, extensive mesh exposure, or failure of the conservative surgical options described above should undergo segmental mesh body and arm excision. In our practice, we offer patients all of the options cited in previous text and tailor the treatment accordingly.
This case report highlights the need for pelvic surgeons to appreciate the proximity of key lower urinary tract structures to the trajectory of the mesh arms. Although rare, the complications described herein can add substantial morbidity. We do not implant transvaginal mesh kits in our practice and therefore cannot comment on the incidence of these complications. Furthermore, these 2 patients had conservative therapies attempted locally and may represent patients with more severe complications. Nevertheless, patients should be counseled on all options for addressing mesh-related complications and should be treated according to the severity of their symptoms.
The authors report no conflict of interest.
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