Transvaginal meshes for pelvic organ prolapse were ordered to be removed from the United States market by the FDA in April 2019. Still, transvaginal mesh sling remains in use for correction of stress urinary incontinence in the United States. The mesh sling can successfully correct urethral hypermobility and, thus, stress urinary incontinence; however, complications that arise from erosion can be harmful to surrounding structures [1]. Thus, the tissue has difficulty healing and warrants resection, debridement of surrounding non-viable tissue, and surgical closure [2]. The surgical repair of mesh erosion can be complicated by lack of viable surrounding tissue, constant presence of vaginal flora, and co-morbidities for poor wound healing [3]. In such cases, utilization of adjunctive treatments or surgical techniques to facilitate the closure of the defect would be beneficial. One such adjunctive treatment is amniotic membrane (AM), which may act as a protective barrier but is also known to have regenerative properties such as anti-inflammatory and anti-scarring properties. Accordingly, AM has been used in various clinical applications, such as dermal and ocular wounds, to help promote accelerated and regenerative healing. While the AM originates from the obstetrical branch of our specialty, its expanding multidisciplinary applications underscore its potential to significantly contribute to the gynecological domain as well. Herein, we evaluate the adjunctive use of ultra-thick AM to augment the surgical repair site for a complex mesh exposure.

A 50-year-old Caucasian female (gravida 2, para 2) presented with vaginal mesh exposure from a transvaginal sling, placed approximately a year ago for stress urinary incontinence. The chief complaints were pain, bleeding, and dyspareunia. Examination revealed an exposed mesh defect that was 4 mm by 2 mm by 5 mm.

Treatment If Relevant

The patient underwent transvaginal excision of the exposed mesh and removal of neighboring scar and non-viable tissue. The vaginal defect was closed with 4-0 poliglecaprone 25 suture (Monocryl; Johnson & Johnson, New Brunswick, NJ) and undyed poliglecaprone 25 suture. Adjunctive ultra-thick AM (Neox RT; BioTissue, Miami, FL) was incorporated into the tissue defect after the mesh was removed and oversewn with two layers of poliglecaprone 25 suture (Figure 1). Care was taken to avoid trauma to the urethra and its meatus.

Outcome and Follow-up

Patient’s recovery was assessed at one month post-operatively and then via telehealth for follow-up, as she was in good health and did not have any complaints. At one month post-op, the operative site was completely covered with vaginal mucosa. There was no granulation tissue present, which can lead to bleeding and can be tender. She had no post-operative urethritis or cystitis. Only one preoperative prophylactic intravenous (IV) dose of cephalosporin was used. The patient was able to resume intercourse one month after the procedure. She did not have pain, bleeding, symptoms of prolapse or of urinary incontinence/leakage as before. Physical examination did not reveal scarring in the operative site and tissues had normal turgor. Six months later, the patient had no complaints.

Amniotic membrane is often considered to be a biological bandage when used in the clinical context of promoting wound healing by acting as a mechanical protective barrier and providing anti-inflammatory and anti-scarring properties to modulate the healing process. Numerous reports have also been published reporting the successful repair of vaginal fistula using placental/umbilical allografts [4],[5]. Posterior colporrhaphy and anal sphincteroplasty procedures have also been complemented with placental/umbilical allograft to help prevent frequent occurrence of this defect [6],[7],[8],[9]. This case report adds to the available literature and demonstrates successful repair of a vaginal mesh erosion with adjunctive ultra-thick AM. Such technique may be considered in cases with extensive tissue damage or in patients with co-morbidities for poor wound healing.

The patient expressed great satisfaction with the procedure, and felt relief to be free from the pain, bleeding, and dyspareunia that had previously affected her quality of life. She was also happy that the healing process occurred so fast, and no longer felt the need to return for follow-up visits as the operative site was completely covered without symptoms as early as one-month post-operation.

Vaginal mesh erosions and fistulas can be a healing challenge and sometimes require multiple procedures with recurrence of open wounds. Vaginal location makes healing challenging due to constant presence of vaginal flora and colon bacteria cross-contamination. This case report suggests complementing vaginal surgical repairs with amniotic membrane (AM) may promote healing without prolonged granulation reaction and excessive fibrosis.