Drs. Miklos and Moore are world experts and innovators in laparoscopic treatment of mesh complications. They are researchers who are widely published in the worlds leading journals.
The abdominal sacrocolpopexy is the “gold standard” procedure to treat moderate to severe vaginal vault prolapse. This procedure has been used for 50 years and has the highest cure rates for the treatment of vaginal vault prolapse. It can be performed through a large abdominal (laparotomy) or four small abdominal incisions (laparoscopy). The procedure utilizes a Y-shaped piece of mesh that is sutured to the vagina and then to the sacrum to elevate the vaginal vault. It has excellent long-term cure rates and low complication rates in the correct surgeons hands.
However, all surgeries can have complications even those utilizing synthetic mesh. Drs. Miklos & Moore have more experience than 99% of surgeons in the world removing sacrocolpopexy mesh and they are two of few surgeons in the world who can remove the mesh via a laparoscopic. This experience comes from not only removing the mesh but also performing more laparoscopic sacrocolpopoexies (LSC) than anyone in the world. They have performed more than 1600 LSC in 18 years. Click below to read their 3-year LSC study on mesh complications.
The first picture you see below is the condition known as vaginal vault prolapse. The second picture is the sacrocolpopexy the “gold standard” procedure for treatment of vaginal vault prolapse. The Y – shaped mesh is attached to the vagina and elevated to the sacrum (aka tailbone).
Despite being the best surgery ever developed for the treatment of vaginal vault prolapse as in all surgeries there are potential complications. Complications directly associated to mesh include: vaginal mesh extrusion, mesh erosion (rectum, bladder, colon), pelvic pain, vaginal pain, pain with sex, infection/abscess formation and pain with defecation.
Vaginal mesh extrusion is one of the most common complications associated with the use of mesh in vaginal reconstructive surgery. The risk of this complication is usually cited to be somewhere between 1-10% and is most often associated with vaginal discharge, bloody discharge, pain with sex, a rough hard area inside the vagina.
The first illustration below shows the mesh extruding through the anterior vaginal wall (i.e. under the bladder). The second illustration shows the mesh extruding through the skin of the posterior vaginal wall (i.e. over the rectum).
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My previous surgery for abdominal sacral colpopexy was not a success! So, I searched for the best doctor who could help me and my situation. Thank goodness I found Dr. Miklos. He is Awesome! At my consultation Dr. Miklos was so thorough; he drew pictures and answered all of my questions.
Not all patients with mesh extrusions are symptomatic. Some patients have no symptoms whatsoever. It has been Drs. Miklos & Moore’s’ experiences that mesh extrusions without symptoms need not be treated, as it is not dangerous to the patient. However, patients suffering from the symptoms of mesh extrusion have a choice between non-surgical and surgical treatment.
In small cases of mesh extrusion the first line of therapy is treating with transvaginal estrogen cream. Applying estrogen every day x 14 days and then 2-3 times per week there after can sometimes help the vaginal skin heal over the mesh extrusion.
In patients with large areas of mesh extrusion or in patients who have failed transvaginal estrogen therapy the next option is surgical removal. Patients can usually have their mesh removed through the vaginal opening with a single incision in the area of mesh exposure. In more advanced cases the complete mesh needs to be removed and this often requires an abdominal approach and in Drs. Miklos & Moore’s hands they perform this using a laparoscope.
There is a risk of pain with intercourse in 1-4% of patients after sacrocolpopexy. The mesh on vagina can develop chronic inflammation, scar tissue and contraction of the mesh. The first illustration shows the normal placement of mesh; please note the lax nature of the mesh. The second illustration shows the tightening of the mesh due to scar tissue.
Conservative therapy involves pelvic floor and vaginal physical therapy, trigger point injections, and vaginal dilators in certain cases. If this does not resolve the issue, the mesh may need to be revised or removed. In the United States Drs. Miklos and Moore are two of only a few surgeons skilled and experienced to remove or revise this type of mesh via laparoscopic outpatient type surgery. Dr. Miklos and Dr. Moore receive referrals from many world-renowned clinics and institutions to perform this surgery on their patients.
Mesh erosion into the bladder or rectum is one of the most rare of complications associated with the sacrocolpopexy. Patients with these conditions will usually complain of deep pelvic pain, general malaise, and pain with sex. If the patient has mesh eroding into the rectum or colon she will often times have a small hole between these structures and the vagina and the patient will complain of foul smelling dark discharge from her vagina. This is bowel movement through the vagina. This condition is called a rectovaginal or colovaginal fistula. She will often complain of pain with bowel movements. If a patient has mesh eroding into the bladder she might complain of blood in her urine, recurrent urinary tract infections, pain with urination and on rare occasion urine leaking from her vagina. This condition is called a vesicovaginal fistula.
The first illustration below shoes mesh eroded into the bladder. The second illustration shows the mesh eroded into the rectum.
There is no conservative treatment for mesh erosion into the bladder, rectum or colon. The only options are to do nothing and live with it or remove the mesh from those areas. Despite being extremely rare complications, Drs. Miklos & Moore have treated both conditions successfully using the minimally invasive technique called laparoscopy.
Sacrocolpopexy infections are extremely rare. It has been Drs. Miklos & Moore’s experience the risk of mesh infection is approximately 1/600 and there is some anecdotal evidence that the infections most commonly occur in patients who have had a simultaneous hysterectomy (compared to patients who have a hysterectomy previously). Patients suffering from infections most commonly experience: general malaise, nausea, fever, and severe abdominal pain. Most infections seem to occur within the first 2 weeks after surgery. It is rare to have an infection 6 months or 2 years later.
The first illustration depicts normal sacrocolpopexy healing without an abscess or an infection. The second illustration shows an area of pus collection i.e. abscess formation.
An infected mesh is a dangerous situation and the initial treatment always begins antibiotics. The diagnosis is usually made with a CT scan. Many surgeons will attempt to treat the abscess/infection conservatively i.e. antibiotic therapy. It has been Drs. Miklos & Moore’s experience that the mesh needs to be removed especially if the abscess and infection has tract its way to the sacrum. If the abscess if isolated to the vagina the infection seems more amenable to antibiotic therapy and to CT guided needle drainage of the pus. If the infection does not appear to get better Drs. Miklos & Moore recommend removing the mesh as soon as possible. In experienced hands this removal can be done using the laparoscope, the technique of choice by Drs. Miklos & Moore.
Drs. Miklos and Moore have been invited to lecture and demonstrate their innovative and cutting edge surgical technique by performing live surgery in Capetown, South Africa at the International Urogynecology Association (IUGA) meeting in August 2016.