Minimally Invasive Vaginal Natural Orifice Transluminal Endoscopic Surgery Technique for Successful Polypropylene Mesh Removal in Pelvic Organ Prolapse: A Case Report

Abstract

In the treatment of pelvic organ prolapse, the insertion of polypropylene mesh is often necessary but can lead to subsequent complications, such as a high incidence of pain and infections, necessitating mesh removal. However, the removal of polypropylene mesh can be challenging due to the risks of postoperative complications and technical difficulties. The key to effective healing often lies in the complete removal of the mesh, but this process is associated with complications, including severe pain and potential foreign body reactions. These challenges underscore the need for less invasive and more precise removal techniques. In our clinical practice, traditional approaches, such as vaginal and open abdominal surgeries, have often been hindered by limited visibility and accessibility at the mesh fixation sites. To address these issues, our team has pioneered the development of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for mesh removal. This innovative and minimally invasive technique, performed through the vaginal route, holds particular promise for repairs within the pelvic cavity. vNOTES not only enhances surgical visibility but also reduces the invasiveness of the procedure. In this case report, we present an 85-year-old female patient, who underwent transvaginal mesh (TVM) insertion at the age of 68 years. The patient developed pain in the left buttock, left lower back, and vulvar region, necessitating the removal of TVM. The vNOTES approach significantly reduced postoperative pain and complications, enabling efficient and safe removal of the polypropylene mesh. Moreover, the pathological examination of the polypropylene mesh, which was causing hip and buttock pain, revealed the presence of poor granulation tissue, indicative of a specific pathological tissue pattern. To the best of our knowledge, this is the first detailed account of the successful application of vNOTES in mesh removal.

Keywords: mesh removal; pelvic organ prolapse; polypropylene mesh; transvaginal mesh; vaginal natural orifice transluminal endoscopic surgery; vnotes.

Figure 1. The path and anatomical diagram of polypropylene mesh

(a) 1.5T MRI T2-weighted sagittal view, TR 4500 ms, flip angle 140 degrees, TE 100 ms, slice thickness 3 mm, interval 3.5 mm, FOV 32 x 36 cm, matrix 320 x 320 (Signa Creator, GE Healthcare, Chicago, Illinois). (b) Illustration of the image in Panel (a) with emphasis on mesh placement. The yellow arrows indicate the polypropylene mesh (illustrated in Figure 1b to highlight the path of the mesh). RA: Rectus abdominis; SB: Small bowel; R: Rectum; V: Vagina; A: Anus; UB: Urinary bladder; Sy: Symphysis pubis; FOV: Field-of-view; TR: Repetition time; TE: Time to echo. Source: The illustration in Figure 1b is an original work by the author, Nobuo Okui.

Figure 2. Overview of the predicted polypropylene mesh placement from surgical records

PM: Polypropylene mesh; RtAA: Right anterior arm; LtAA: Left anterior arm; RtPA: Right posterior arm; LtPA: Left posterior arm; Sy: Symphysis pubis, IT: Ischial tuberosity; IP: Ischial spine; OF: Obturator foramen. Source: This illustration is an original work by the author, Nobuo Okui.

Figure 3. The vNOTES model and illustration

(a) A model with the GelPOINT V-Path Transvaginal Access Platform (Applied Medical, Rancho Santa Margarita, California) fixed in place. (b) An illustration depicting the use of the GelPOINT V-Path Transvaginal Access Platform for laparoscopic mesh extraction. Sy: Symphysis pubis; UB: Urinary bladder; R: Rectum; vNOTES: Vaginal natural orifice transluminal endoscopic surgery. Source: Figure 3b is an original work by the author, Nobuo Okui.

Figure 4. vNOTES model

(a) Introducer, (b) sleeve, (c) obturator, (d) gel seal cap, (e) Alexis wound retractor, (f) instrument shield, (g) laparoscopic grasping forceps, (h) laparoscopic scissors, and (i) laparoscopic needle holder (a-f: Applied Medical, Rancho Santa Margarita, California; g-i: Olympus Corporation, Tokyo, Japan). vNOTES: Vaginal natural orifice transluminal endoscopic surgery.

Figure 5. Laparoscopic surgery photos

(a) A view showing the area around the border of the coccygeal muscle and pubococcygeus muscle after adhesions have been cleared, with polypropylene mesh inserted, displaying fragile and easily bleeding scar tissue. (b) An image taken by making an incision in the anal direction from Figure 4a, identifying the polypropylene mesh within the adhesion tissue. The yellow-dashed line indicates the overview of the polypropylene mesh, and the blue-dashed line indicates the incision to release the mesh within the uterine removal site. PM: Polypropylene mesh; C: Coccygeal muscle; PC: Pubococcygeus muscle; R: Rectum.

Figure 6. Changes in pain and OAB before and after the surgery

(a) Changes on VAS. The blue line indicates left hip pain; the green circle indicates left flank pain; the red circle indicates perineal pain; and the purple circle indicates lower abdominal pain. (b) Changes in OABSS. The horizontal axis represents before and after surgery. VAS: Visual analog scale, OABSS: Overactive bladder symptom score.

Figure 7. Extracted mesh and pathological tissues

(a) Photograph showing the extracted mesh arranged in a dried, inserted, and fixed format. The black arrows and labels b-f indicate areas where part of the mesh is missing, corresponding to the parts excised in the respective pathology photographs (panels b-f). (b) Histological image of the mesh inserted between the bladder and vagina. (c and d) Histological images near the boundary between the coccygeal muscle and the pubococcygeal muscle. This area is a cause of back pain. (e and f) The region causing left buttock pain is excised by incising toward the anal direction for comparison with Figure 6b. The gray arrows indicate the incomplete granulation due to a foreign body; the red arrows indicate hemorrhage; the blue arrows indicate foreign body giant cells; the red closed triangle indicates the rupture of muscle fibers; and * indicates the evidence of tears in the blank shot state due to the polypropylene mesh fibers breaking down from age-related degradation. The images in panels b-f were stained with hematoxylin and eosin (H&E) and captured at an optical magnification of 40x. Va: Vacuoles formed due to the mesh peeling off during the preparation of the pathological specimen; RtPA: Right posterior arm; LtPA: Left posterior arm; RtAA: Right anterior arm; LtAA: Left anterior arm.