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Effect of operative technique on mesh exposure in laparoscopic sacrocolpopexy
William B Warner1, Sonali Vora, Eric A Hurtado
1Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD, USA. homegrown95@yahoo.com
Objectives:
To determine if opening the vaginal cuff during laparoscopic sacrocolpopexy influences the rate of mesh exposure.
Methods:
A total of 390 medical records were retrospectively reviewed for demographic information, operative technique, and relevant outcomes.
Results:
Eleven mesh exposures (2.8%) and 14 suture extrusions (3.6%) were found, none involving visceral organs. Mesh exposure was more common when the vaginal cuff was opened, either during hysterectomy or when allowing transvaginal attachment of mesh in patients with a prior hysterectomy (4.9% vs 0.5%; relative risk [RR], 9.0, P = 0.012). In cases where concomitant hysterectomy was performed, a higher mesh exposure rate was seen in open-cuff hysterectomy (total vaginal hysterectomy/laparoscopically assisted vaginal hysterectomy) compared to supracervical hysterectomy (4.9% [9/185] vs 0% [0/92]; P = 0.032). Mesh exposure was more common when the mesh was sutured laparoscopically compared with transvaginally in patients undergoing open-cuff hysterectomy (14.3% [5/35] vs 2.7% [4/150]; RR, 5.4; P = 0.013). Permanent suture extrusion was significantly associated with laparoscopic versus transvaginal suturing of mesh (5.6% vs 0.6%; RR, 8.8; P = 0.010). Five patients underwent reoperation for mesh exposure, whereas most suture extrusions were asymptomatic; and all were managed nonsurgically.
Conclusions:
We found that preserving the integrity of the vaginal cuff led to a lower incidence of mesh exposure in patients undergoing laparoscopic sacrocolpopexy. When hysterectomy is indicated, a supracervical technique should be strongly considered as the mesh exposure rate was significantly lower. If removal of the cervix is indicated, the risk for mesh exposure remains low and should not preclude total hysterectomy, though transvaginal mesh attachment may be preferable.
Insights
Preserving the vaginal cuff during laparoscopic sacrocolpopexy significantly reduces mesh exposure. Supracervical hysterectomy is recommended when hysterectomy is needed to lower mesh exposure risks.
Area of Science:
- Urogynecology
- Minimally Invasive Surgery
- Pelvic Reconstructive Surgery
Background:
- Pelvic organ prolapse (POP) affects many women, with sacrocolpopexy being a common surgical treatment.
- Laparoscopic sacrocolpopexy (LSC) is a minimally invasive approach for POP repair.
- Mesh exposure is a known complication of LSC, potentially requiring further intervention.
Purpose of the Study:
- To investigate the impact of opening the vaginal cuff during LSC on the incidence of mesh exposure.
- To compare mesh exposure rates between different surgical techniques involving the vaginal cuff and hysterectomy.
Main Methods:
- Retrospective review of 390 patient records undergoing LSC.
- Analysis of demographic data, operative techniques (vaginal cuff status, hysterectomy type, mesh suturing method), and outcomes.
- Statistical comparison of mesh exposure and suture extrusion rates based on surgical variables.
Main Results:
- Mesh exposure occurred in 2.8% of patients, with higher rates when the vaginal cuff was opened (4.9% vs 0.5%).
- Open-cuff hysterectomy (total or laparoscopic-assisted vaginal) had a higher mesh exposure rate than supracervical hysterectomy (4.9% vs 0%).
- Laparoscopic mesh suturing in open-cuff cases showed higher exposure (14.3%) than transvaginal (2.7%). Suture extrusion was also higher with laparoscopic suturing (5.6% vs 0.6%).
Conclusions:
- Maintaining vaginal cuff integrity during LSC is crucial for minimizing mesh exposure.
- Supracervical hysterectomy is associated with significantly lower mesh exposure rates when hysterectomy is necessary.
- While total hysterectomy can be performed, transvaginal mesh attachment may be preferred to reduce exposure risk.
