An unusual mesh erosion after transobturator tape replacement

Headnote

Keywords: Complication, erosion, incontinence, mesh

Introduction: The transobturator tape (TOT) sling procedure is a variation of the midurethral sling procedures and gaining popularity. Mesh-related complication rate after transvaginal mesh application is about 15-25% and mesh erosion is up to 10% for these indications. Synthetic non-absorbable polypropylene mesh has become the dominant reconstructive material for gynecologic surgery. Novel complications from mesh became apparent in years. Patients may present with mesh exposure, rejection, vaginal bleeding, pelvic pain, dyspareunia, and partner irritation during sex. More than 30,000 vagianal mesh related complication reported in United States recently.

Most of the mesh erosion areas located under the urethra. Mesh erosion at thigh Incision area is very rare. We presented an unusual case, unilateral mesh erosion at thigh Incision area and its management.

Case Presentation: Fifty-five years old, parity five woman admitted to our clinic for mesh exposure at left thigh Incision area. She had transobturator tape replacement surgery for SUI three years ago in her medical history. She had no any other medical condition. After physical examination we saw the mesh at left thigh Incision area (Figure 1a). There was a granulomatous skin reaction around the Incision area. After the evaluation we offered wound revision to patient.

At the operation, the woman was placed in the lithotomy position and we inject the local anesthetic around the erosion area. After that we excised the granulomatous reaction area with ten blade (Figure 1b). We stopped the excision when we reached the healthy skin. After that we cut the 1 cm protruding part of the polypropylene mesh. The thigh Incision is closed in a running fashion with 2-0 delayed-absorbable suture (Figure 1c). Patient was discharged from hospital at the same day Two weeks after intervention wound fully recovered. Two months after intervention no mesh erosion observed at thigh Incision area (Figure 1d).

Discussion: Urinary incontinence is defined as involuntary leakage of urine. Approximately half of the women complain from urinary incontinence. Usage of synthetic mesh during SUI surgery is being used increasingly in hopes of achieving more durable improvement6. Mesh related complication became more often in last decade. American Food and Drug Administration warned about possible complication of transvaginal meshes in 2011. Erosion through tissue planes is the prIncipal obstacle in mesh based repair. Real prevalance of mesh related complications is unknown. Most complications of mesh surgery occurs one to five years after surgery. A careful clinical examination, imaging and cyctoscopy are required for the diagnosis and determine the management strategy of mesh erosion. Main management method for mesh erosion is local estrogen therapy and mesh resection. However removal of the mesh was more difficult if the initial operation has been long ago.

Mesh-related complications are a groving problem for gynecologists in their daily practice. Previous studies showed that, Surgical intervention looks advantageous. In this case we reported a mesh erosion at thigh Incision area. New developments in mesh material optimization are currently expected. The single Incision mini-slings can avoid most of the thigh Incision related complications.