Conservative surgical management of Mersilene mesh suburethral sling erosion.

OBJECTIVE: The aim of this study was to describe conservative surgical management of polyethylene terephthalate (Mersilene, Ethicon, Inc, Somerville, NJ) mesh suburethral sling erosion as an alternative to sling removal. STUDY DESIGN: Seven women who had undergone suburethral sling procedures with Mersilene mesh were found to have varying degrees of mesh visible in the vagina at 4 to 12 weeks after the operation. Three women with erosions <5 mm were treated in the office and 4 women who had 6 to 30 mm erosions underwent inpatient surgical revision, which consisted of trimming of mesh when needed, excision of granulation tissue, and re-covering of the erosion in 2 layers. RESULTS: All 7 patients have been followed up for 6 to 37 months. Only 1 woman who underwent inpatient surgical revision had a recurrence (4 mm); this was treated successfully in the office. CONCLUSION: Vaginal erosions in suburethral sling procedures with Mersilene mesh can be managed initially with our conservative surgical technique.

Double pessary use in grade 4 uterine and vaginal prolapse.

BACKGROUND: Certain situations dictate conservative management of grade 4 uterine or vaginal vault prolapse in women. The reduction of a prolapse may not be possible if the vagina cannot retain a single pessary. We have used double pessaries in the management of this condition. TECHNIQUE: With the patient in the dorsal lithotomy position, either a Donut or Inflatoball (Milex Products Inc., Chicago, IL) pessary is inserted and pushed into the vagina as far as is comfortable. A second pessary, either a flexible Gellhorn or Shaatz (Milex Products Inc.), then is placed caudad to the first. EXPERIENCE: We have used this approach in five women who have been followed for 7-15 months. There have been no erosions or vaginitis and all the women experienced symptomatic relief. CONCLUSION: In women who want or require conservative management of grade 4 prolapse and are unable to retain a single pessary, the placement of two pessaries often will be successful.

The effect of posterior wall support defects on urodynamic indices in stress urinary incontinence.

OBJECTIVE: To determine if posterior vaginal wall defects affect urodynamic indices and mask stress urinary incontinence. METHODS: Ninety women with grade 0, 1, 2, or 3 posterior wall defects were evaluated prospectively by complete urodynamics to assess their urinary complaints. None had severe anterior or apical support defects. Urethral pressure profilometry and cough stress test were performed with the posterior wall in the unretracted position and then with the posterior wall retracted using a split speculum. Analysis of covariance was used to compare adjusted mean differences in maximum urethral closure pressure, functional urethral length, and units of leakage volume during the cough stress test in the unretracted and retracted positions among the posterior wall grade groups. RESULTS: In women with grade 3 posterior wall defects, there were significant changes from the unretracted to the retracted position in maximum urethral closure pressure of -7.0 cm H20, (99% confidence interval [CI] -12.4, -1.6), functional urethral length of -0.3 cm (99% CI -0.5, -0.1), and leak volume units of +0.7 (99% CI 0.4, 1.0) during the cough stress test. There were four women with grade 3 posterior wall defects who demonstrated potential stress incontinence when their posterior wall was retracted. CONCLUSION: A grade 3 posterior wall defect may artificially raise maximum urethral closure pressure, increase functional urethral length, and mask urinary stress incontinence during a cough stress test. Women with grade 3 posterior wall defects should be tested with the posterior wall retracted during urodynamic evaluation.