MESH REMOVAL & LAPAROSCOPIC NERVES-RELEASE
All pelvic, perineal and obstetrical procedures potentially expose patients to pelvic nerve injuries. Even when reports about surgical pelvic nerves are rare in current literature, the rates of pelvic nerves damage after secondary to pelvic organ prolapse surgery are unknown and probably widely underestimated.
Damages happening during interventions are due to coagulation, suturing, ischemia or cutting and induce troubles of sensation, pain and dysfunctions starting immediately after the procedure or after a short interval of several days. In contrast, nerve lesions by fibrotic tissue (fibrotic entrapment) or vascular compression / entrapment usually require several months or even years to develop. Implantation of sutures or mesh material or hematoma / abscess formation in proximity to nerves constitute a risky situation for both kinds of neuropathic pain. Transvaginal fixation of the vaginal cuff is the classical high-risk procedure for pudendal nerve injury by direct lesion while suturing the sacrospinous ligament as is entrapment when a hematoma or an abscess develops. More recent interventions using mesh material for the fixation of the pelvic organs (vagina, uterus, rectum) to the sacral bone may also expose patients to risk of nerve damage.
In surgical nerve damages, since pain and dysfunction develop right after the procedure, a possible surgical complication may be noticed early by both the surgeon and the patient. This usually leads to re-intervention that can possibly result in etiologic treatment. In fibrotic entrapment of the pelvic nerves, the situation is much more complex. Since pain appears after an interval of several months or years, relationships between both the intervention and the apparition of pain is not evident. Diagnosis is even more difficult as neuropathic pain is not located in the pelvis, but at a distance in the lower back, the buttock, the pudendal areas or in the lower extremities; all these pain locations are usually correlated with orthopedic or neurosurgical conditions.
Surgical intervention with mesh implantation by the vaginal approach for vaginal prolapses seems to expose patients more to fibrotic entrapment, especially when they involve new devices developed for vaginal implantation by the technique of blind needle driving and minimal dissection, because when any bleeding occurs, hematomas cannot drain and tend to develop even more fibrotic tissue.
Techniques of laparoscopic mesh-implantation lead to surgical damages and fibrotic entrapment to the pelvic nerves located within the pelvic cavity.
Neuropathic pain by lesions of pelvic nerves are reported as “burning pain” (allodynia) or “electrical pain” located in the dorsal face of the thigh, the perianal / genital and perineal areas, the buttock, the lower back, the internal or the anterior areas of the thigh. A lesion of a pudendal nerve itself induces an isolated pudendal pain, usually unilateral and without any incontinence – as long as pudendal destruction is not on both sides. Fibrotic or vascular entrapment induces sexual dysfunction, hyperactivity or hypersensitivity of the bladder and / or rectum, while surgical nerve damages lead to urinary / fecal incontinence or bladder retention (incapacity for bladder voiding).
When a diagnosis of a pelvic nerve injury is noticed, meticulous clinical evaluation and precise diagnosis are mandatory. When the exact injured nerve is determined, laparoscopic exploration must be then considered as the first step in management of patients, since it results not only in a proper etiological diagnosis but also allows for decompression of the nerves and / or implantation of electrodes for neuromodulation in the damaged nerves (less than 5% of the patients). Mesh can be removed, if necessary, by the vaginal and / or laparoscopic approach.
Laparoscopic exploration must be then indicated as soon as possible, before nerve damage becomes irreversible and before the process of chronification of the pain begins.
At Possover International Medical Center, we pride ourselves on accurately diagnosing the cause of discomfort and utilizing the least invasive technique possible to remove the mesh and provide relief. Prof. Possover is one of the few surgeons in the world who can remove mesh via a laparoscopy.