While the cervical stump may serve as a tissue barrier for a patient who has undergone a laparoscopic sacrocervicopexy for organ prolapse, mesh erosion and bacterial infection can still occur.
Janelle Moulder, MD, Brigham and Women’s Hospital, presented a unique case of mesh migration into the cervical os at the 41st Global Congress of the American Association of Gynecologic Laparoscopists. This migration resulted in chronic inflammation and impaired healing.
The 55 year-old patient presented with copious grayish vaginal discharge 10 months after an uncomplicated laparoscopic supracervical hysterectomy and sacrocervicopexy with stage 2 anterior, stage 1 uterine and stage 2 posterior prolapse. Her examination revealed well-vascularized vaginal tissue, Moulder said, and a normal appearing cervix with no obvious evidence of mesh extrusion. The patient had been maintained on vaginal estrogen for atrophy and was treated for a presumptive diagnosis of bacterial vaginosis. Imaging did not reveal a fistula.
Symptoms persisted. Vaginoscopy under anesthesia revealed mesh protruding through internal cervical os and a giant cell body formation, a reaction to mesh material.
The patient underwent laparoscopic mesh excision with trachelectomy. To reinforce vault suspension, uterosacral ligament suspension was performed. Six weeks postoperatively the patient was noted to have a well-healed vaginal cup and continued apical support.
Moulder noted higher rates of erosion with total hysterectomy compared to supracervical hysterectomy. “The thought is that the cervix provides an additional barrier to the vaginal mucosa and more robust, well vascularized tissue with which to anchor the mesh,” Moulder said. “However, any foreign body can be pro-inflammatory, which can impact wound healing. A giant cell formation on our patient’s pathology confirms this hypothesis.”
A patient can experience mesh erosion months or even years after surgery.
This patient’s cervical canal allowed for an extrusion of mesh despite having a preserved cervical stump in this patient’s case. “With increased performance of laparoscopic sacrocervicopexy,” Moulder said,” vigilance regarding mesh related complications will be paramount for early identification and treatment for those patients.”