Cystoscopic removal of transvaginal mesh: Long‐term outcomes

Abstract Objectives This study's aim is to evaluate the long‐term quality of life and functional outcomes following cystoscopic excision of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) mesh extruded into the urinary tract in women. Patients and Methods A retrospective chart review was performed of all cases of cystoscopic removal of extruded mesh at our high‐volume tertiary care centre between April 2013 and August 2021. Postoperative patient‐reported outcomes were collected via questionnaires: Urogenital Distress Inventory Short Form (UDI‐6), EQ‐5D‐5L Visual analogue scale, ICIQ‐Satisfaction (ICIQ‐S) and additional questions regarding postoperative sexual function. Results During the study period, 27 women with a median age of 61 years (45–87) underwent cystoscopic mesh removal surgery using either Ho‐YAG laser (56%) or bipolar loop resection (44%). The most common presentation of mesh extrusion was recurrent urinary tract infections (67%). Other presenting complaints were pain (41%), urinary urgency ± incontinence (41%) and voiding difficulties (18%). Long‐term follow‐up outcomes from 20 patients (median follow‐up: 24 months) showed that mesh removal was rated successful by 80%, and 100% would choose to have the surgery again if in the same situation. Recurrent SUI was reported by 45% of respondents, and urinary urge incontinence was found in 50%. For patients who answered the sexual function questions, 50% reported improved sexual function postmesh removal (6/12). Conclusions Cystoscopic removal of extruded female SUI and POP mesh is associated with high patient satisfaction and low morbidity in appropriately selected patients at 2‐year median follow‐up. A patient‐centred shared decision‐making process is essential in counselling patients regarding options and expected outcomes following mesh removal surgery.


| INTRODUCTION
Transvaginal synthetic mesh has been commonly used to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The main types include retropubic midurethral mesh tension-free vaginal tapes (TVT), transobturator mesh tapes/slings (TOT), single-incision mini-slings, and transvaginal POP mesh kits. 1 Mesh extrusion into the urinary tract may occur in 5% of cases and can lead to serious problems of lower urinary tract symptoms (LUTS), haematuria, pain, recurrent urinary tract infections (UTIs), difficulties voiding, urinary incontinence and dysuria 2 Patients may also experience a change in sensation in the leg, vagina, perineum or elsewhere. 3 Tijdink et al. found that pain was the most common complaint of mesh erosion.
These symptoms can significantly reduce quality of life (QoL) and can occur in approximately 10% of women who undergo mesh surgery. 4 Some countries have recently recommended 'high vigilance' or restricted use of transvaginal POP and/or SUI mesh. 5 Patients with complications may be offered surgical mesh removal via cystoscopic, laparoscopic, robotic-assisted and/or an open approach. 6 Open surgery includes partial or complete removal of mesh components. 7 Tijdink et al. found that there was no difference in symptom relief between patients who underwent open partial versus open complete excision of mesh, in the short term. However, for those who had had POP mesh, recurrence of POP was more common after complete excision. 4 This group also found that complications seemed to be more frequent in those who had complete mesh excision, although this difference was not statistically significant.
There is certainly potential for significant morbidity from open surgery that should not be underrated, and it may not be feasible in all patients, but equally leaving mesh behind may cause problems in the future and make full mesh removal difficult.
Cystoscopic removal is done by intravesical resection of the mesh with electrode loop and transurethral resection/excision or ablation using a holmium laser. 8 The advantages of endoscopic removal are that it may carry a lower morbidity risk, with shorter operating times, less blood loss and faster recovery time. 9,10 However, patients are more likely to require further intervention or repeat procedures, and it may not improve certain symptoms such as pelvic pain. Endoscopic mesh removal may have a relatively good success rate in the short term as was shown in a recent systematic review by Sobota et al., wherein only 22% (collated sample size = 41) of patients required a repeat cystoscopic treatment of their eroded mesh. 11 However, the median follow-up time was 6 months ± 17.0 (range 1-65 months), highlighting that long-term evidence was limited.
The objectives of this work were to assess the postoperative course and complications of patients who underwent cystoscopic excision of urinary tract extruded mesh as well as the patient-reported QoL and functional outcomes at long-term follow-up. We aim to utilise this information to improve patient counselling regarding manage-

| PRE-OPERATIVE PLANNING AND OPERATIVE TECHNIQUE
Initial patient consultation took place in the Urology department at our centre. The patient's symptoms and investigations were reviewed, and surgical options were outlined. Cases were discussed in a multidisciplinary team (MDT) meeting. After discussion, the outcome was communicated to the patient and preferred course of management confirmed. A shared informed decision-making process was used to aid the patient in deciding on the extent of mesh removal and surgical approach employed. This included offering full or partial removal of the mesh and the risks associated with each procedure.
All cystoscopic mesh removal was performed by one functional urology subspecialist or their senior trainee with appropriate supervision. Preoperative antibiotics were administered, and all cases were completed under general or spinal anaesthetic.
For bladder mesh erosion, either endoscopic bipolar loop resection or laser ablation was utilised. Bipolar loop resection was using a 26Fr sheath and continuous irrigation. Laser ablation was using a Ho-YAG laser (fibre size: 550 or 1000 μm) through a laser working element The eroded mesh plus any calcifications were destroyed with the laser. The site of extrusion was also ablated deeper than the visible mesh to encourage scar formation to heal over the previous extrusion site.
Any urethral mesh erosion was exclusively managed via laser ablation rather than bipolar loop in a similar fashion making sure that no mesh was visible in the intraluminal urethral wall.
All patients had clinical follow-up to assess amelioration of their symptoms including a flexible cystoscopy at 3-6 months from their procedure to assess for recurrence.

| RESULTS
During the 8-year study period, 70 women presented with mesh erosion into the urinary tract that elected for surgical excision. Of those, 27 women with a median age of 61 years (range 45-87 years) selected transurethral mesh removal surgery for mesh extrusion into the urinary tract (Table 1).
Operative technique applied was either Ho-YAG laser destruction of mesh (n = 19, 56%) or bipolar loop resection/fulguration (n = 15, 44%). The most common subtype of mesh encountered was retropubic TVT for SUI (Table 2). Extrusion into the bladder was most common.

| DISCUSSION
There is a growing body of evidence that complications following transvaginal SUI and POP mesh can be delayed in presentation and have a significant impact on QoL. 13 Mesh extrusion into the urinary T A B L E 1 Patient demographic information.  Success was defined as no further erosion seen on last follow-up, but long-term PROMs were not evaluated. Recent work by Allagany, Dekalo, and Welk reported upon the largest single series of endoscopic laser ablation of SUI mesh extruded into the urethra. 14 For the 29 women in their series, they used the UDI-6 to evaluate PROMs with a median follow-up length of 3.7 years. They concluded that there was minimal associated morbidity when the Ho-YAG laser was used for extruded urethral mesh, with long-term acceptable UDI-6 scores. Our study also utilised the UDI-6 as well as the ICIQ-S (Outcome score), the EQ-ED-5L VAS, and questions particularly focused on sexual function. Sexual dysfunction can be overlooked in patients who have had complications following transvaginal surgery when the focus is on urinary tract symptoms.
In our series, the median time from mesh insertion surgery to recognition and management of mesh extrusion was 9 years which is slightly longer than in some previously reported work. 14,15 A pro- pain. 16 In our patients, the most common presenting complaint leading to discovery of mesh extrusion was recurrent UTI. Although sexual dysfunction is a known possible complication from mesh insertion, there is limited evidence that this problem improves after mesh removal. 17 Only 60% of our survey responders answered the questions on sexual function; however, this could be because they are no longer sexually active so that may have steered them to answer, 'not applicable'. Of the responders, 50% of the women reported improved sexual function currently compared with before mesh removal. Further work focused on sexual function after mesh excision surgery is needed.
Overall, cystoscopic mesh removal was rated as highly satisfactory, as exemplified by 100% of responders answering that they would have mesh excision again if in the same situation (ICIQ-S, Figure 1). There were no complications greater than Clavien-Dindo In the absence of high-level evidence, a shared-decision process between the surgical team and the patient is key to mesh removal surgery. Patients need to be presented with all surgical options and the pros and cons of each including the lack of long-term data. In some countries, there are now mesh complication centres that can offer patients all forms of treatment in a multidisciplinary approach. 3 In conclusion, we reported on a large series of cystoscopic mesh removal cases for women with mesh extrusion into the urinary tract including long-term follow-up PROMs. Transurethral surgery for SUI and POP mesh extrusion was associated with high patient satisfaction, low morbidity and high success rates. Half of the patients had improved sexual function following removal of the mesh. A patientcentred shared decision-making process is essential in counselling patients regarding options and expected outcomes following mesh removal surgery.

AUTHOR CONTRIBUTIONS
Katherine Anderson: data collection, data analysis and manuscript preparation. Marie-Aimée Perrouin-Verbe: data collection and manuscript revisions. Lily Bridgeman-Rutledge: data collection, data analysis and manuscript preparation. Rachel Skews: data collection and manuscript revisions. Hashim Hashim: data collection and manuscript revisions.