ACOG and AUGS issues recommendations for management of mesh and graft complications in gynecologic surgery.

Courtesy: Sanders firm 

The American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) have jointly developed a committee opinion of the management of mesh and graft complications in gynecologic surgery.

The document provides surgeons with guidance for managing complications after mesh surgery. It also stresses the importance of good clinical history and detailed physical examination.

Knowledge of exact location of the mesh/graft is a must, and case notes/operative notes from the index procedure are best in providing the necessary information.

Diagnostic testing includes cystoscopy, proctoscopy, colonoscopy, or radiologic imaging.

The procedures most commonly associated with mesh complications are Midurethral Sling, Abdominal sacral colpopexy and transvaginal mesh.

The recommendations by American College of Obstetricians and Gynecologists and the American Urogynecologic Society includes the following:

• Short-term voiding dysfunction after placement of a synthetic midurethral sling is common and, if improving, can be managed expectantly for up to 6 weeks. However, retention (inability to empty the bladder) or small-volume voids with large postvoid bladder residual volume should receive earlier intervention.
• Long-term voiding dysfunction (typically 3 months or longer) after a midurethral sling placement are managed by referral to a clinician with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist.     
• Asymptomatic exposures of monofilament macroporous meshes can be managed expectantly in the hope that spontaneous reepithelialization can occur.
• A trial of vaginal estrogen can be attempted for small (eg, less than 0.5-cm) mesh exposures, if not successful primary reclosure is advised.
• Persistent vaginal bleeding, vaginal discharge, or recurrent urinary tract infections (UTIs) after mesh placement should prompt an examination and possible further evaluation for exposure or erosion.
• Pelvic pain (including dyspareunia), possibly related to nonexposed mesh, is complex, may not respond to mesh removal, and should prompt referral to a clinician with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist.
• Mesh removal surgery should not be performed unless there is a specific therapeutic indication.

The full text of committee opinion of the management of mesh and graft complications in gynecologic surgery can be accessed here.