Mesh erosions rates are high when total vaginal hysterectomy is performed with laparoscopic or robot-assisted sacrocolpopexy.
Toronto-Mesh erosions rates are high when total vaginal hysterectomy is performed with laparoscopic or robot-assisted sacrocolpopexy, say investigators from the University of California, San Diego.
On the other hand, these minimally invasive sacrocolpopexy procedures done with concomitant supracervical hysterectomy have acceptably low rates of mesh erosions, said first author Jasmine Tan-Kim, MD, a senior clinical fellow in reproductive medicine at UC San Diego and an obstetrician/gynecologist at Kaiser Permanente, San Diego. Not only did this and every mesh procedure come under heavy fire at this meeting, but critics also took issue with calling these procedures "minimally invasive" and even questioned the need for post-hysterectomy sacrocolpopexy.
Dr. Tan-Kim and her colleagues, led by Emily Lukacz, MD, came to their conclusions based on a retrospective look at surgical records and follow-up for 188 women who underwent these procedures at their institution between November 2004 and January 2009 for advanced uterovaginal or vaginal vault prolapse.
In both the post-hysterectomy and supracervical hysterectomy groups, the mesh erosion rate was 5%. In the concomitant total vaginal hysterectomy group, however, the mesh erosion rate was 23%, Dr. Tan-Kim reported at the 2010 joint meeting of the International Continence Society and the International Urogynecological Society in Toronto.
More erosions in lap group
The majority of erosions were exposed mesh into the vagina (16); one exposure was of suture only. One of the vaginal exposures was the sole erosion among the women who had undergone supracervical hysterectomy. That patient also had a colpotomy during the procedure. There were two patients with mesh exposures into the bladder (both of whom had some form of bladder integrity compromise at the time of their index procedure).
"After this study, we have decided to discontinue the practice of placing mesh if a cystotomy occurs intraoperatively," Dr. Tan-Kim explained.
There were no differences among the concomitant hysterectomy and previous hysterectomy groups in terms of time to detection of the erosions. Comparing those who did and did not have erosions revealed no demographic differences (smoking, diabetes, menopausal, or hormonal status), prolapse characteristics, or surgical characteristics, except for concomitant posterior repair and hysterectomy. In a multivariable regression analysis, only total vaginal hysterectomy remained a significant contributor to mesh erosion (OR: 5.67, 95% CI: 1.88-17.10, p=.002).
"Based on these data," Dr. Tan-Kim concluded, "surgeons should consider supracervical hysterectomy as the procedure of choice in association with minimally invasive sacrocolpopexy for uterovaginal prolapse unless removal of the cervix is otherwise indicated."