FEMALE UROLOGY

Management of vaginal erosion of polypropylene mesh slings
Kobashi KC, Govier FE
Continence Center at Virginia Mason, Seattle, Washington, USA
J Urol. 2003; 169: 2242-3

• Purpose: The SPARC (American Medical Systems, Minneapolis, Minnesota) polypropylene sling has recently been introduced as an alternative delivery system to TVT (Ethicon, New Brunswick, New Jersey) tension-free vaginal tape for placement of a tension-free mid urethral sling. Erosion must always be considered a risk of synthetic materials. We present 4 cases of vaginal erosion of polypropylene mesh placed with this system and the successful conservative management done.
• Materials and Methods: A total of 90 patients received a SPARC polypropylene pubovaginal sling at our institution between October 1, 2001 and October 1, 2002. During followup 3 of our patients and 1 patient with tension-free vaginal tape who was referred from elsewhere presented with vaginal exposure of the mesh.
• Results: Two patients described persistent vaginal discharge 6 weeks postoperatively, including 1 who complained primarily of partner discomfort during sexual intercourse. Two patients were completely asymptomatic and mesh erosion was discovered at routine physical examination 6 weeks postoperatively. Pelvic examination demonstrated vaginal exposure of the mesh in all cases. Each patient was observed conservatively and 3 months postoperatively all 4 had complete spontaneous epithelialization over the mesh. None had stress incontinence, urgency or urge incontinence, all emptied the bladder to completion and all patients were completely satisfied with the procedure.
• Conclusions: The recent literature suggests that polypropylene mesh erosion should be treated with complete removal of the sling material. We present 4 cases of vaginal erosion of polypropylene slings that were managed conservatively with observation and resulted in complete spontaneous healing. Sling preservation with continued patient continence and satisfaction is a feasible option in those with vaginal exposure of polypropylene mesh.
  
• Editorial Comment
  The authors describe their experience with four patients with vaginal erosion of their polypropylene mesh sling into the vagina. None of the patients had an erosion of the urinary tract (i.e. into the urethra or into the bladder). Two of the patients were completely asymptomatic while the other two had persistent vaginal discharge including one whose partner complained of pain with sexual relations. All four patients were treated conservatively and at 3 months post-operatively all the erosions had complete epithelialization with a normal exam noted. None of the patients had any voiding dysfunction such as recurrent stress urinary incontinence or urge incontinence during their course of treatment.
  This is an important paper with regards to management of those patients who have vaginal erosion of their artificial material slings. It is succinct and well written. Many times in practice a patient will be identified who has deemed herself an operative success but has an erosion of artificial material noted in the vagina. The next clinical question is usually: should this patient be subjected to complete removal of the sling if they are indeed asymptomatic with good urinary control? This paper addresses this very point. They illustrate that with a minimalist approach there was complete epitheliazation and no voiding dysfunction.
  In addition to the reported clinical results, the article is valuable for the discussion on sling removal versus oversewing of the vaginal mucosa over the sling. Excellent points are made regarding the potential impact of the loosely woven polypropylene mesh with regards to its large pores and allowing tissue in-growth. They make a direct contrast between the construction and properties of the polypropylene as opposed to other synthetic materials such as polyester and silicone (1). In addition, the authors do point out that none of the patients in their report had a urinary tract erosion such as into the urethra and bladder which would be a different malady to both diagnose and treat (2). This paper gives clinicians food for thought with regard to management of those patients who have a simple vaginal erosion after a polypropylene mesh sling. Perhaps the rate of vaginal erosion is higher and the clinician does not appreciate its presence secondary to the lack of symptoms and its eventual auto-resolution. The authors should be lauded for delineating a plan of action that allows us to be more heartened with the counsel of simple sexual abstinence and tincture of time for this post operative complication.

References
1. Clemens JQ, DeLancey JO, Faerber GJ, Westney OL, McGuire EJ: Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy. Urology 2000; 56: 589-94.
2. Sweat SD, Itano NB, Clemens JQ, Bushman W, Gruenenfelder J, McGuire EJ: Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction. J Urol. 2002; 168: 144-6.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA