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Mesh Complications & Removal — POP and SUI Mesh

Mesh complications in urogynecology represent a major clinical and regulatory concern, encompassing a spectrum of adverse events following synthetic-mesh use for pelvic organ prolapse (POP) repair and stress urinary incontinence (SUI) surgery (midurethral slings).

For the indication-and-augmentation framework see Mesh & Graft-Augmented Prolapse Repair. For the broader prolapse-repair atlas see Prolapse Repair (04g). For the female-SUI sling decision-framework see Female SUI Database.

Regulatory Background and Current Status​

The FDA issued a public-health notification in 2008, followed by a 2011 safety communication. In 2016, it reclassified surgical mesh for transvaginal POP repair as a Class III device requiring premarket approval. On April 16, 2019, it ordered the remaining manufacturers to stop selling and distributing these products in the United States after their applications failed to demonstrate reasonable assurance of safety and effectiveness; none is currently FDA-approved and marketed for this indication. The 2019 joint ACOG/AUGS POP bulletin included an interim update acknowledging the order.[3][38]

Scope of the 2019 FDA order. It applies to transvaginal mesh products for POP only. It does not apply to:

  • Midurethral mesh slings for SUI, which have a separate indication, evidence base and risk profile. Single-incision and full-length sling evidence should also be interpreted by device and approach.[30][38]
  • Transabdominal mesh for sacrocolpopexy, a distinct POP approach.[38]

Availability and restrictions outside the United States vary by jurisdiction; check the current local regulator before discussing a mesh-augmented vaginal POP repair.

IUGA / ICS Classification System​

The IUGA / ICS 2011 joint terminology classifies complications directly related to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery by category, time and site (CTS). It applies to insertion complications and healing abnormalities. A code gives the category numeral and division letter, an optional pain letter, then the time and site. The written code omits a "C" before the category. In the source's Figure 4 case, an anterior vaginal mesh exposure of 20 mm by 15 mm with dyspareunia at 5 months is coded 3Bc/T3/S1.[5]

The term "erosion" is discouraged. Use prominence or contraction (no epithelial separation), exposure (mesh seen through separated vaginal epithelium) and extrusion (for example, a loop of tape protruding into the vagina).[5]

CategoryMeaningDivisions
1Vaginal, no epithelial separation (prominence, contraction, palpable mesh fibers)A asymptomatic abnormal finding; B symptomatic (unusual discomfort or pain, dyspareunia in either partner, bleeding or discharge); C infection; D abscess
2Vaginal exposure of 1 cm or lessA to D as for category 1
3Vaginal exposure over 1 cm, or extrusionA to D as for category 1
4Urinary tract compromise or perforation4A small intraoperative defect (for example, a recognized bladder perforation); 4B other lower tract complication (persistent perforation, fistula, calculus, or retention requiring surgery); 4C ureteric or upper tract
5Rectal or bowel compromise or perforation5A small intraoperative defect; 5B rectal injury or compromise; 5C small or large bowel injury or compromise; 5D abscess from bowel injury
6Skin or musculoskeletal6A asymptomatic; 6B symptomatic (discharge, pain, lump); 6C infection, including sinus tract; 6D abscess
7Patient compromise7A bleeding including hematoma; 7B major resuscitation or intensive care; 7C mortality

Pain letters follow the division: a none, b provoked only at vaginal examination, c pain during intercourse, d pain during physical activity, e spontaneous pain. They apply to symptomatic, infected and abscess findings, for example 3Bc.[5]

AxisCodes
Time (T)T1 intraoperative to 48 h; T2 48 h to 2 months; T3 2–12 months; T4 over 12 months. Time is the date of clinical diagnosis.
Site (S)S0 systemic, no specific site (used only for 7B and 7C); S1 vaginal, at the suture line; S2 vaginal, away from the suture line; S3 trocar passage (extraperitoneal, bladder or rectal complications, not intra-abdominal); S4 other skin or musculoskeletal site; S5 intra-abdominal (bowel perforation or obstruction).

Reporting rules from the source:[5]

  • List every complication, and code multiple complications in one patient, or early and late complications, separately.
  • If a complication progresses, use the highest final category; a small exposure that enlarges moves from category 2 to 3, and an asymptomatic finding that becomes symptomatic moves from A to B.
  • The system does not record the mesh type, so pair it with the material and procedure.
  • Recurrent prolapse is not a complication. Urinary tract infection, bulking-agent complications and intraperitoneal adhesions are not classified. Voiding dysfunction is not classified, except retention that needs surgery (4B).

The ICS/IUGA classification calculator generates the full code; do not assign a category from symptoms alone.[5]

In the Miklos 2016 three-center surgical-removal series (445 patients; 587 classified complications), the most common classification categories were spontaneous pain (1Be, 32.5%) and dyspareunia (1Bc, 14.7%); most patients presented > 1 year after implantation (mean 3.68 years).[6]

Complication Rates by Procedure Type​

ComplicationTransvaginal mesh (POP)Midurethral sling (SUI)Sacrocolpopexy
Mesh erosion / exposure11.8% (transvaginal permanent mesh trials)[1]1.9% (pooled SUI mesh studies)[7]10.5% estimated at 7 years (abdominal CARE cohort)[2]
Chronic pain6.7% (pooled vaginal and abdominal POP mesh; not transvaginal-specific)[7]0.6% (pooled SUI mesh)[7]Variable
Dyspareunia4.8% de novo severe (1/21 at 24 months); 13.0% severe overall (3/23 assessed at 24 months; PROSPECT mesh kits)[13]No sling-specific estimate; 19.0% of sexually active women in a mixed POP/SUI implant cohort (mean 20.8 months after surgery)[12]Variable
De novo SUIHigher than native-tissue repair (RR 1.50; 17 RCTs, 2,001 women)[1]N/AN/A
Reoperation for mesh complications6.1% had surgery for exposure in transvaginal permanent-mesh trials[1]—11/215 (5.1%) had surgery for mesh complications by year 7 in E-CARE[2]
Bladder injuryHigher than native-tissue repair (RR 3.67; 14 RCTs, 1,997 women)[1]VariableVariable

The MacCraith 2021 systematic review of nearly 293,000 patients confirmed that mesh erosion is significantly higher after POP surgery (4%) than SUI surgery (1.9%) (OR 2.13), and chronic pain rates are dramatically higher in the POP group (6.7% versus 0.6%; OR 11.02). Both complications typically manifest within the first year after surgery (mean about 307 and about 326 days).[7]

Specific Complications​

Mesh exposure / erosion​

The most well-characterized complication. For transvaginal POP mesh, the Yeung 2024 Cochrane review reported an exposure rate of 11.8%, with 6.1% requiring surgical intervention.[1] For abdominal sacrocolpopexy, the CARE trial long-term follow-up estimated a 7-year mesh-erosion probability of 10.5% (95% CI 6.8–16.1%).[2] The Bretschneider 2024 5-year follow-up of laparoscopic or robotic total hysterectomy and sacrocolpopexy confirmed gradually increasing exposure risk over time.[8]

Risk factors.

  • In one single-center retrospective cohort of mixed mesh procedures, larger vaginal incisions were associated with exposure; the study did not validate its >2.5 cm ROC cutoff in a separate cohort.[9]
  • Sexual activity was an independent risk factor for exposure in the same single-center retrospective cohort (77.6% versus 61.8% sexually active).[9]
  • In one retrospective cohort, BMI was higher among women with vaginal mesh exposure than among those without it (27.1 vs 25.9 kg/m²), but its adjusted association with exposure was not statistically significant (OR 1.064, 95% CI 0.961–1.178; P=.233).[9]
  • Concurrent total hysterectomy (for sacrocolpopexy).[10] In the Çetin Arslan mixed-procedure cohort, concomitant hysterectomy was not significantly associated with exposure (P = .119).[9]
  • In two sequential cohorts, lightweight polypropylene mesh with a resorbable poliglecaprone component was associated with fewer graft-related complications than heavier-weight polypropylene mesh: 13/178 assessed patients (7.3%) versus 23/101 (22.8%) at median follow-up of about 93 versus 97 months.[11]

Pain and dyspareunia​

Pain is increasingly the most common indication for mesh excision in referral practice, and the most common presenting symptom in the Miklos series.[6][29] Risk factors for de novo pelvic pain include younger age, fibromyalgia, early postoperative pain, poorer physical health, and somatization.[12] In the PROSPECT trial secondary analysis (Reid 2021), de novo severe dyspareunia at 24 months occurred in 1.4–4.8% across repair types, with mesh kits showing the highest rate (4.8%).[13]

Voiding dysfunction (midurethral slings)​

In a 600-woman randomized midurethral-sling trial cited by ACOG/AUGS, incomplete bladder emptying occurred in approximately 20% on postoperative day 1, declining to 6% at 2 weeks and 2% at 6 weeks.[14] Most cases are self-limited. Long-term bladder-outlet obstruction can lead to high-pressure voiding, ureteral reflux, upper-tract dilation, and detrusor decompensation, requiring sling release; see Urethrolysis.[14]

Organ perforation​

In the Yeung 2024 Cochrane review, the summary-of-findings table estimated bladder injury at 18 per 1,000 women receiving permanent transvaginal POP mesh versus 5 per 1,000 after native-tissue repair (14 randomized trials; 1,997 women; low-certainty evidence).[1] Rectal perforation, ureteral injury, and vesicovaginal fistula are rare but reported and should be excluded with cystoscopy, proctoscopy or imaging when symptoms suggest visceral involvement.[15]

Management — ACOG / AUGS Committee Opinion 694 Framework​

ACOG/AUGS Committee Opinion No. 694 provides general management guidance; the 2020 AUGS/IUGA joint position statement addresses specialist decisions and grades its proposed algorithms.[14][50]

ScenarioManagement
Asymptomatic vaginal exposure (type 1 monofilament macroporous)Observation may be reasonable after examination and shared decision-making; this differs from unrecognized urinary-tract erosion.[14]
Small symptomatic vaginal exposure (< 0.5 cm)A 6–12-week trial of topical vaginal estrogen may be considered; comparative evidence is limited. Reassess persistent symptoms.[14]
Persistent or larger exposuresSpecialist evaluation for site, amount of mesh and symptoms; limited excision with reclosure or more extensive removal may be considered. A Martius flap to cover an exposed vaginal POP mesh has been reported as a selected case technique.[14][39]
Pelvic pain / dyspareunia related to non-exposed meshComplex — may not respond to mesh removal. Refer to an FPMRS specialist.[14]
Voiding dysfunction after slingACOG/AUGS permits observation with bladder drainage for up to 6 weeks when incomplete emptying improves; for retention or small voids with high residuals, it calls for earlier intervention and considers sling loosening or release after about 2 weeks.[14] French national guidance recommends direct surgical sling relaxation within 7 days for acute retention (expert agreement), except when preoperative detrusor hypocontractility favors intermittent self-catheterization.[58] Persistent dysfunction at ≥ 3 months merits specialist evaluation.[14]
Mesh-removal surgeryDo not remove an asymptomatic implant solely because transvaginal POP mesh was withdrawn from the US market; balance the specific therapeutic goal against removal morbidity.[14][38]

Infected sacrocolpopexy mesh. Sacral discitis or osteomyelitis warrants specialist and infectious-disease/spine input; antibiotics may be followed by drainage, mesh removal or debridement when an abscess is present. For pelvic abscess after sacrocolpopexy, French national guidance recommends removing infected mesh as completely as feasible, obtaining operative cultures, draining the collection and giving targeted antibiotics (expert agreement).[55][56] It permits antibiotics without mesh removal only for selected nonseptic patients with type I macroporous monofilament polypropylene mesh, microbiologic documentation, multidisciplinary antibiotic selection and duration, and close surveillance (expert agreement).[55][56] The AUGS/IUGA statement grades consideration of CT-guided drainage plus antibiotics without removal C based on three abscesses without mesh exposure, all diagnosed within 14 days of sacrocolpopexy.[14][50]

For a small symptomatic exposure, Karram describes selecting office-based excision when the exposure is under 1 cm, readily visible and accessible with office instruments, and surrounded by healthy vaginal tissue: local anesthesia, mobilization of the adjacent epithelium, a right-angle clamp placed between mesh and tissue before trimming, and tension-free closure of the vaginal epithelium when feasible. This is an attributed selection approach rather than an outcome-validated size cutoff, and it is distinct from the < 0.5 cm threshold above for a topical-estrogen trial.[42]

Multiple-interventions reality​

  • Abbott 2014 multicenter study: 60% of women with mesh complications required ≥ 2 interventions; 49% required surgical intervention as initial treatment; among those initially managed nonsurgically, 59.3% ultimately required surgery.[16]
  • Kowalik 2021 cross-sectional study of 59 women: about 75% reported symptom improvement; 14/59 (24%) underwent a subsequent operation, and 17/59 (29%) had undergone or were scheduled for one at median 1.7-year follow-up.[17]

Diagnostic workup​

Before choosing tests, review the index procedure and implant, prior revision operative reports and symptom timing; map mesh exposure and pain on pelvic examination, with pelvic neurologic examination when indicated. Use cystoscopy, proctoscopy, colonoscopy or imaging to answer a specific management question, and arrange specialty input according to suspected organ or nerve involvement.[14][50]

Sentinel Symptoms Warranting Evaluation​

Persistent vaginal bleeding or discharge, recurrent UTIs, new hematuria or bladder pain, pelvic pain, dyspareunia, or anal discharge or bleeding after mesh placement should prompt examination and targeted evaluation for exposure or organ involvement.[14][59] New or persistent back pain after sacrocolpopexy should prompt assessment for sacral discitis or osteomyelitis and specialist referral. ACOG/AUGS describes noncontrast MRI as typically the most appropriate diagnostic approach in this setting.[14] For suspected spine infection, ACR rates both MRI of the affected spine without and with IV contrast and MRI without IV contrast as usually appropriate initial studies.[54]

Imaging Evaluation​

The ACR Appropriateness Criteria for pelvic-floor dysfunction emphasize that no single imaging modality is universally best; the optimal choice depends on the specific anatomic region being evaluated and the clinical question. Pelvic-floor ultrasound and MRI have complementary roles.[31]

Pelvic-floor ultrasound (translabial / transperineal / transvaginal)​

Pelvic-floor ultrasound can be particularly useful for the sub- and periurethral portions of midurethral slings and vaginal mesh. Synthetic polypropylene is often echogenic, while MRI conspicuity varies by material, sequence and surrounding tissue. Neither modality replaces examination or indicated cystoscopy.[14][32][33]

Strengths.

  • Inexpensive, readily available, quick, easy to learn; can be performed in the office or intraoperatively with a standard curvilinear transducer.[34]
  • Differentiates retropubic from transobturator slings by sling-arm position; demonstrates sling disruption, folding, urethral impingement, and erosion not apparent on physical exam or cystoscopy.[34]
  • Real-time dynamic assessment during Valsalva.
  • In one study cited by the ACR, physical examination detected only 72% of the mesh or slings visualized by transvaginal ultrasound (TVUS).[31]
  • 3D endovaginal ultrasound (EVUS) provides tomographic reconstructions confirming the presence or absence of vaginal-wall mesh, identifying residual mesh after excision, and assessing mesh relationship to the urethral lumen, information necessary for surgical planning.[32]

Diagnostic performance for mesh complications.

IndicationModalitySensitivitySpecificityNPVNotes
Lower-urinary-tract mesh exposure (n = 100; 3 events)Translabial/transvaginal pelvic-floor US100% in this small sample98–100%100% in this sampleOnly one urethral and two bladder exposures occurred.[35]
Sling erosion into urethra / bladder (n = 124; 15 at surgery)Translabial ultrasound, counting intraluminal or intramural mesh93%72%—Sensitivity rose when intramural mesh was included, at the cost of specificity; cystourethroscopy had 67% sensitivity for the study's surgical endpoint. The tests answer different anatomic questions.[36]

Limitations.

  • Cannot visualize retropubic components of urethral slings.
  • Cannot visualize extrapelvic components traversing the obturator foramen or ischiorectal fossa.
  • Cranial / apical sacrocolpopexy mesh is poorly seen.[31]

For ultrasound-page detail on PFUS technique and reference ranges, see Ultrasound — Pelvic Floor (Transperineal / Translabial).

MRI pelvis (contrast according to the clinical question)​

MRI can complement ultrasound for subacute or chronic complications after pelvic-floor surgery, especially global anatomy or deeper components outside the ultrasound field. The sequence and need for IV contrast depend on the suspected complication; the ACR does not prescribe one scan for every mesh concern.[31][37]

Indications where MRI is preferred.

  • Retropubic sling components (better than ultrasound).
  • Obturator and ischiorectal sling components.
  • Sacrocolpopexy mesh integrity, presacral hematomas.
  • Mesh infection, abscess, discitis / osteomyelitis.
  • Peripheral nerve assessment via MR neurography.
  • Global pelvic-floor anatomy for surgical planning.

For MRI-page detail see MRI — Pelvis.

Complementary roles — ultrasound vs MRI​

FeatureUltrasound (TUS / TVUS / TPUS)MRI pelvis
Periurethral / suburethral slingOften conspicuous and dynamically assessableLess conspicuous for some material
Retropubic sling armsLimited fieldBroader field
Obturator / ischiorectal componentsLimited fieldBroader field
Sacrocolpopexy meshLimited apical/cranial fieldBroader field for deeper components
Dynamic assessment (Valsalva)Real-timePossible with a tailored protocol
Mesh vs scar differentiationMesh often echogenicVariable by material and sequence
Global pelvic-floor anatomyLimitedBroader field
Cost / accessibilityLow cost, office-basedHigher cost, less accessible
Intraoperative useYesNo

Imaging-evaluation bottom line​

Translabial / transperineal ultrasound is useful for vaginal and periurethral mesh localization and dynamic assessment when expertise is available. Cystoscopy remains important when urinary-tract involvement is suspected. MRI can help assess deeper retropubic, obturator or sacrocolpopexy components and broader pelvic pathology; choose imaging to answer the patient's specific question.[14][31][35][36][37]

These scans should be performed and interpreted by pelvic-floor specialists with core competency in pelvic-floor ultrasound; incidental findings are common and clinical correlation is needed.[32]

Complete vs Partial Mesh Removal​

The central clinical question (whether complete or partial mesh removal yields superior outcomes) remains incompletely resolved, with no randomized controlled trials to guide decision-making.[18] Doyle's partial-versus-total midurethral-sling removal review included only retrospective studies; prospective single-group mesh-excision cohorts also report outcomes.[20][22][27]

The 2020 IUGA/AUGS joint position statement distinguishes five levels of removal extent: mesh revision (no removal, or trimming a small edge without disrupting implant integrity), partial vaginal excision (a vaginal segment removed or transected), complete vaginal excision (all mesh in contact with the vagina removed), extravaginal excision (additional retropubic or groin components removed, anatomically specified), and total mesh excision (removal of the entire implant). A complete vaginal excision can therefore leave extravaginal mesh in place and should not be presented to a patient as a total explant. Office trimming of exposed vaginal mesh is listed as a separate, limited procedure.[50]

POP mesh complications​

Bergersen 2021 Urology (n = 78 patients undergoing mesh removal for pain / dyspareunia).[19]

  • In the 78-patient pain/dyspareunia subgroup, symptoms resolved or improved in 85.9% (mean follow-up 17.25 months).[19]
  • No significant difference between complete (46.7% resolved, 40.0% improved) and partial removal (51.5% resolved, 33.3% improved; p = 0.82).[19]
  • Complete removal associated with numerically higher recurrent symptomatic POP (31.1% versus 15.2%, p = 0.12; not statistically significant).[19]
  • Overall, 23 patients (30.3%) required additional reconstructive procedures.[19]

Midurethral sling complications​

Doyle 2022 Obstet Gynecol SR/meta-analysis of 45 studies.[20]

  • Partial sling removal had significantly lower rates of postoperative SUI versus total removal (OR 0.46, 95% CI 0.22–0.96).[20]
  • In separate single-group study pools, postoperative SUI was 19.2% after partial removal and 48.7% after total removal.[20]
  • Both approaches were similar for pain resolution, bladder-outlet obstruction, mesh exposure, and lower-urinary-tract symptoms.

Palmieri 2024 was a separate cohort of 204 patients undergoing vaginal continence-mesh removal; 80.5% reported recurrent SUI, and video-urodynamics at about 4 months found SUI in 67.6% of those tested.[21]

Outcomes by indication for removal​

The indication for removal is a predictor of surgical success.

IndicationImprovement rateKey finding
Mesh exposure only73.9% (17/23 PGI-I respondents at 6–24 months; mixed mesh types, Pace)[22]; exposure successfully treated in 95% in a separate transvaginal POP-mesh series (Crosby)[24]Exposure had the highest patient-reported improvement among the Pace indication groups
Exposure + pain58.3% (35/60 PGI-I respondents at 6–24 months; mixed mesh types)[22]Intermediate patient-reported improvement among the Pace indication groups
Pain alone33.3% (7/21 PGI-I respondents at 6–24 months; mixed mesh types)[22]Poorest patient-reported improvement; PFDI / PFIQ scores did not improve despite VAS pain reduction

Pace 2021 BJOG prospective longitudinal study of 173 women undergoing complete vaginal mesh excision demonstrated this pattern (p = 0.03 across groups). VAS pain scores decreased across all groups, but validated quality-of-life measures (PFDI, PFIQ) did not improve in the pain-only group.[22]

Souders 2022 14-year single-center series (113 patients with at least 6 months of follow-up) reported pain resolution in 50% and dyspareunia resolution in 52%, while 21% had persistent pain and 4% developed de novo pain.[23] Crosby 2014 Obstet Gynecol cohort confirmed similar symptom-resolution patterns after operative management of transvaginal mesh complications.[24]

Surgical Approaches​

Transvaginal excision​

The most commonly used approach, employed in 84.5% of removals in the 14-year single-center Souders series.[23] For vaginal exposure after sacrocolpopexy, ACOG/AUGS describes excision of visible vaginal mesh as an option; persistent exposure may require abdominal or laparoscopic revision. For other implants, the route depends on mesh location and extent and the therapeutic goal.[14] When a more complete excision is planned and the mesh body has been mobilized, Karram describes clamping and tying the mesh arms before transection, since an arm may become vascularized after implantation and bleed if simply cut; this is an operative preference for legacy transvaginal POP mesh.[42]

Stepwise approach for sacrocolpopexy mesh erosion[25]​

  1. Initial transvaginal excision of exposed mesh: sharp dissection of the mesh away from the vagina and any adherent tissue with downward traction, excising as high as feasible before closing the vaginal defect; entry into the peritoneum can facilitate extraction.[51] South's retrospective sacrocolpopexy-exposure series reported symptom resolution after vaginal excision in 16/30 evaluable women (53.3%; mean vaginal-group follow-up 14 months), and three women underwent three vaginal attempts.[25] For type I polypropylene sacrocolpopexy mesh exposure, the 2020 AUGS/IUGA statement assigns Grade D to considering initial office trimming for symptomatic exposure and separately advises against repetitive trimming.[25][50] It assigns Grade C to considering partial vaginal mesh excision with epithelial closure and/or partial colpocleisis for sacrocolpopexy mesh exposure and discourages repeating vaginal excision after failure.[25][50] Reassess the next treatment step. When a sinus tract is present at the vaginal apex, one series describes enlarging the opening as needed to pass a 17-French cystoscope and advancing it toward the sacrum to visualize mesh extent during dissection and excision.
  2. After failed vaginal excision in South's retrospective sacrocolpopexy-exposure series, 7/7 women undergoing abdominal excision had symptom resolution at follow-up; 2 sustained bowel injury (1 requiring resection), and 1 each had wound breakdown, fever readmission or acute coronary syndrome.[25]
  3. Laparoscopic sacrocolpopexy mesh excision is described as feasible in Mohr’s 2023 Int Urogynecol J step-by-step report, which documents repeat prolapse repair during the same operation in one of two cases.[26] A 2024 expert consensus warns that complete removal of mesh, tacks or sutures at the sacral attachment may be impossible and carries a risk of major hemorrhage.[57]

Robot-assisted mesh removal​

Fong 2022 J Endourol prospective series of 30 patients: complete or near-complete mesh removal in 83.3%, median operative time 240 minutes. Concomitant reconstructive procedures in 40% of patients. Three Clavien-Dindo grade 3b complications (ureteric / bladder injury, omental bleed, groin wound infection).[27]

For a patient whose suprapubic or thigh pain persists after a retropubic or transobturator sling despite conservative care or vaginal excision, dedicated open or minimally invasive routes to the retained sling arm have been described. For suprapubic pain after a retropubic sling: open extraperitoneal exposure through an infraumbilical or Pfannenstiel incision, splitting the rectus muscles and developing the space of Retzius, or a laparoscopic or robotic transperitoneal (with division of the median umbilical ligaments and urachus and a bladder drop) or extraperitoneal approach, following the arm from the pubic bone through the endopelvic fascia to the skin; cystoscopy is recommended after excision. For thigh pain after a transobturator sling: a 6–8 cm incision 1–2 cm lateral to the inferior pubic ramus, division of gracilis and, if needed, adductor brevis and obturator externus, and tracing of the mesh to the obturator membrane, with the dead space closed over a drain. In a retrospective multicenter series of 8 patients who underwent thigh dissection to remove transobturator mesh arms (5 with a sling alone, 2 with both sling and POP mesh, and 1 with POP mesh alone), 5 were cured of pain and/or infection at a mean follow-up of 6 months.[40] These are reserved for centers experienced with the approach.[40][41]

Mesh exposure into the urethra or bladder​

Endoscopic excision. Transurethral resection or holmium-laser excision of intravesical mesh has been described.[49] A systematic review of 198 women reported initial/final success of 67%/92% with laser excision and 80%/98% with electrode-loop or scissor excision; complication rates were 24% and 28%, respectively, and stress urinary incontinence was reported in 21% of women in each treatment group; after electrode-loop or scissor excision, 3 of 90 women (3%) developed a vesicovaginal fistula and 2 (2%) had an intraperitoneal bladder perforation that needed a further procedure.[47] For urethral extrusion specifically, a 2026 systematic review pooled five holmium-laser series: 57/73 women were reported successfully treated at mean 27-month follow-up, 24/73 had incontinence and two developed urethrovaginal fistulas.[53] Partial-wall involvement may make endoscopic treatment technically infeasible; removal of the vaginal mesh component with urethral reconstruction is an established approach.[53] Repeat cystoscopy was inconsistent, so clearance was not uniformly verified.[53] A vesicoscopic approach has been reported when transurethral access or visualization is limited: in one series of 5 patients, the eroded mesh was completely removed vesicoscopically with no recurrence at a median follow-up of 30 months.[48]

Transvaginal excision — urethral exposure. An inverted-U vaginal flap exposes the urethra for excision of exposed mesh, with primary urethral closure and separate, non-overlapping closure of the periurethral fascia and vaginal flap in three layers; an interposition flap such as a Martius flap is used at the surgeon's discretion.[43][45] A Foley catheter is typically left for 7–14 days, with VCUG used selectively rather than routinely.[45] In a small prospective follow-up series of 5 patients after urethral mesh-perforation repair, 4 had persistent stress incontinence at a mean of 54 months, despite subsequent pelvic-floor therapy or a salvage sling in most.[46]

Transvaginal or abdominal excision — bladder exposure. A similar inverted-U exposure with two-layer bladder closure and vaginal-flap closure has been described transvaginally, with temporary ureteral stenting to help identify and protect the ureter.[43][44] Route depends on location: an exposure below the trigone is usually accessible vaginally, a supratrigonal exposure may need an abdominal approach, and an exposure at or within 5–10 mm of a ureteral orifice may require an abdominal approach with ureteral reimplantation.[43][45]

Positioning, Catheter Use and VTE​

Positioning follows the excision approach already described above: dorsal lithotomy for transvaginal excision, and lithotomy positioning with the abdominal or laparoscopic/robotic access used for a transabdominal excision (as for a repeat Sacrocolpopexy when the same mesh is re-approached from above).

A urethral (Foley) catheter is commonly placed intraoperatively to decompress the bladder and, when excision is near a midurethral sling or bladder-neck mesh, to help palpate the urethral course during dissection.[14]

No mesh-excision-specific VTE recommendation exists; apply the general reconstructive-pelvic-surgery risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility, and the added exposure of an abdominal or laparoscopic/robotic approach) on the VTE Prophylaxis page.

Concomitant Reconstructive Surgery​

Recurrent prolapse and SUI are common sequelae of mesh removal, making concomitant or staged reconstruction an important consideration.

  • In Bergersen’s pain or dyspareunia subgroup after POP-mesh removal, 23 patients required additional reconstructive procedures (reported as 30.3%).[19]
  • ACOG/AUGS reports recurrent SUI after sling release for obstruction in approximately 40% of women; in one 107-woman release series, 49% reported recurrent SUI and 14% underwent repeat SUI surgery.[14] Separately, 72/99 selected women had persistent or new incontinence after transvaginal sling removal; success after one minimally invasive intervention was 81% for stress-predominant, 86% for urge-predominant and 75% for mixed incontinence (defined by UDI-6 responses, continence satisfaction and no further intervention at last visit; mean follow-up 23 months).[14][28]
  • In Fong’s 30-patient robot-assisted mesh-removal series, concomitant reconstructive procedures were performed in 40%.[27]
  • For lower urinary tract perforation by a midurethral sling, total or near-total mesh excision, urinary-tract reconstruction and a concomitant autologous rectus-fascia pubovaginal sling in a single operation has been described. In a retrospective series of 21 women (14 urethral and 7 bladder perforations; transvaginal or combined transvaginal and abdominal approaches; mean follow-up 22 months), the mesh complication and primary symptom resolved in all, and continence was achieved in 10 of 14 after urethral perforation and in all 7 after bladder perforation.[52]

Counseling Considerations​

Per ACOG Committee Opinion 694.[14]

  • Do not offer prophylactic removal solely because a mesh product is no longer marketed; assess an asymptomatic implant and the patient's goals individually.[38]
  • Counsel about the complex trade-offs between positive and adverse pelvic-floor functions with each additional procedure.
  • Pain may not resolve after mesh removal, particularly when pain is the sole indication.[14][53] Refer to an FPMRS specialist experienced in mesh removal; when pain occurs without a demonstrable anatomic abnormality, include specialist pain input in treatment planning.[14][53]
  • Multiple procedures were common in two selected cohorts: in Abbott's retrospective series of 347 women evaluated at tertiary referral centers for mesh complications after SUI and/or POP surgery, 60% received ≥2 interventions; in Kowalik's cross-sectional series of 59 women after mesh-revision surgery, 14 (24%) underwent another operation and 17 (29%) had undergone or were scheduled for one at a median follow-up of 1.7 years.[16][17] -Doyle's 45 included studies were retrospective and heterogeneous, while Pace's prospective single-group cohort assessed patient-reported outcomes after complete vaginal mesh excision rather than comparing partial versus total sling removal; 50/173 women completed 24-month questionnaires.[18][20][22]
  • Mesh-removal surgery should be planned with a surgeon familiar with the index procedure and anticipated complication; complex cases merit FPMRS referral. Evidence linking excision-provider or center volume to removal outcomes remains limited.[14][29][50]

Current Clinical Implications​

  • Transvaginal POP mesh: no FDA-approved product is currently marketed for this indication in the United States.[38] Existing asymptomatic implants do not require removal merely because marketing ended.[14][38]
  • Midurethral slings remain an evidence-supported SUI surgical option distinct from transvaginal POP mesh; counsel on their own benefits, risks and local availability.[4][38]
  • Sacrocolpopexy with type 1 mesh remains an apical-prolapse option distinct from vaginal POP mesh. Success depends on the outcome definition and follow-up; mesh exposure can rise over time.[8][38]

See Also​

Videos​

Robotic Sacrocolpopexy Mesh Removal
Operative video
Transvaginal Sling Excision
Operative video, Cleveland Clinic (graphic)
Robotic Release of Obturator Nerve Entrapment After Retropubic TVT
Krentel H, et al. Facts Views Vis ObGyn 2024
Open source videoRead the article

References​

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