Laparoscopic Removal of Eroded Sacrocolpopexy Mesh and Fistula Repair 9 Years After Hysterectomy.

Abstract

L aparoscopic sacrocolpopexy shows superior outcomes for uterine prolapse, with success rates up to 96%–99%. The robotic-assisted laparoscopic sacrocolpopexy and laparoscopic sacrocolpopexy have similar efficacy rates when compared with open approaches, with less blood loss and pain, and quicker recovery. A rare complication of sacrocolpopexy is mesh erosion, occurring in 2.4%–23% of cases. A concomitant total hysterectomy at the time of sacrocolpopexy, laparoscopic placement of mesh, and inappropriate mesh materials are known risk factors for mesh-related complications.Mesh erosion after sacrocolpopexy is also associated with smoking, an immunocompromised state, diabetes mellitus, prior radiation therapy, immunosuppression, corticosteroid use, malnutrition, chronic disease of the liver or renal system, and younger age at the time of surgery. Erosion is more often reported with polytetrafluoroethylene mesh, Gore-Tex (WL Gore, Flagstaff, Ariz), and silicone-coated mesh. Begley et al observed different rates of mesh erosion with different materials used as follows: 0% for fascia, 0% for polypropylene, 9% for Gore-Tex, and 19% for silicone-coated mesh. Gore-Tex multifilament mesh has pores less than 10 μm (microns), allowing for bacteria to infiltrate through while neutrophils cannot. Similarly, silicone forms a “pseudocapsule” where a bacteria-containing biofilm forms, trapping bacteria, and allowing for subclinical indolent infection. The ideal mesh for sacrocolpopexy is made from monofilament polypropylene, such as Marlex (CR Bard, Haverhill, Mass), Prolene (Ethicon, Somerville, NJ), and Restorelle Y mesh (Coloplast, Minneapolis, MN). The pores are greater than 75 μm allowing fibrous tissue and neutrophils to eradicate bacteria. Several investigators have demonstrated that a concomitant total hysterectomy at the time of sacrocolpopexy is a significant risk factor for mesh erosion. Warner et al reported a 4.9% risk of mesh exposure with open-cuff hysterectomy compared with 0% in supracervical. Cundiff et al identified a 14% mesh erosion rate with sacrocolpopexy performed with total hysterectomy. Tan-Kim et al reported a rate of 23% compared with 5% with supracervical. Bensinger et al similarly found a 7-fold greater chance of mesh erosion with total hysterectomy compared with supracervical. Mesh erosionmay be the result of inflammation