Presacral hemorrhage incurred during the dissection of the sacral promontory is one of the most feared complications of ASC, as well as one of the more commonly reported in the literature [3]. Bleeding from the presacral space may be large volume because the bleeding vessels may retract into the sacrum. Historically, in the 1970s, the operation was described with fixation of the mesh graft to the level of S3–S4 below the sacral promontory in an attempt to create a more natural vaginal axis [8]. After a life-threatening hemorrhage at this site, Sutton advocated for fixation higher on the sacral promontory at the S1–S2 level [9]. This site allows better visualization of the middle sacral artery and the slight difference in vaginal axis has not resulted in negative outcomes. Careful dissection at the sacral promontory should be used to avoid laceration of the unseen presacral vessels. Excessive blunt dissection should be avoided to prevent shearing of the presacral veins. Monopolar cautery should be used precisely, and diathermy cautery may be helpful as well. If uncontrollable bleeding is incurred which is not amenable to direct cautery, it may be managed with stainless steel thumbtacks [10], bone wax, or a figure of eight stitch [11]. It is important to be aware of the left common iliac vein, as this structure is frequently located more medial than the artery and can be injured during exposure of the promontory.

Injury to the bladder or bowel may occur during dissection or inadvertently. Care should be taken at all points of bladder dissection to maintain a full thickness dissection and avoid cystotomy. Additionally, we try to avoid excessive cautery in the dissection of the bladder from the vagina. If a bladder injury is detected, it should be closed in two layers with absorbable suture and an adequately sized urethral catheter should be left for bladder drainage. At this point, it would be at the discretion of the surgeon whether to proceed with mesh attachment to the vaginal apex. Mesh should not be placed adjacent to or in proximity to the cystotomy as it might predispose to erosion of mesh into the bladder or fistula formation [12]. If vesical injury is missed, patients may present with fever, pain secondary to urinoma or urinary ascites.

Enterotomy with any fecal or enteric soilage precludes placement of mesh. The bowel injury should be repaired and the case concluded. If enterotomy is missed, patients with unrecognized bowel injuries often present 1–2 days postoperatively and may lack the typical signs of peritonitis. Patients may present with low-grade fever and leukopenia with a left shift. The clinician should maintain a high index of suspicion and order a computed tomography (CT) scan in these patients.

The ureters should be identified early on in the case to avoid injury from dissection or entrapment or kinking in the culdoplasty sutures. To insure patency of the ureter, we perform cystoscopy after the conclusion of the case with D50 for clear visualization of the effluxing urine .

Key signs and symptoms of vaginal mesh erosion include persistent pain, discharge, and occasionally dyspareunia for the woman and/or her partner. Suture erosions are typically asymptomatic [13, 14]. A comprehensive review of ASC quoted an overall mesh erosion rate of 3.4% [3] although rates of erosion quoted in the literature vary [13, 15–17]. While mesh erosions after ASC typically occur 4–24 months after surgery [13, 15], they may also present several years later [18]. Because of this, determining an accurate erosion rate in series is complicated by length of follow-up. Additionally, mesh type, surgical technique, and modifiable factors may affect the rate of erosion. Predicting mesh erosion can be difficult. Retrospective cohorts have found that mesh exposure is greater in ASC in patients with advanced stage (three or more) prolapse, when performed with concomitant hysterectomy, and patients who have had three or more vaginal procedures [19].

Mesh type appears to affect erosion rates based on comparison of the literature although there have been no standardized trials comparing different materials. In the Nygaard meta-analysis , polypropylene carried an erosion rate of 0.5% in comparison to 3.1% for polyethylene terephthalate (Mersilene^®; Ethicon/Johnson & Johnson, Somerville, NJ, USA), 3.4% for polytetrafluoroethylene (Gore-Tex^®; W.L. Gore, Flagstaff, AZ, USA), 5.0% for polyethylene (Phillips Sumika, Polypropylene Co., Houston, TX, USA), and 5.5% for Teflon^® (E.I. DuPont de Nemours and Co., Wilmington, DE, USA) [3]. No conclusions were made in this review regarding whether certain mesh types predispose to erosion because in this setting they could not control for other variables (method of graft placement, concurrent hysterectomy, etc.). However, certainly, particular mesh materials are more at risk for erosion. Govier and colleagues found a 23.8% graft complication rate (mesh erosion or infection) in a retrospective review of 21 patients who underwent ASC using a silicone-coated polyethylene preformed graft [16]. A subanalysis of the Colpopexy and Urinary Reduction Efforts (CARE) study found a nearly fourfold increased risk of mesh erosion if Gore-Tex mesh was used compared to non-Gore-Tex mesh, which reached statistical significance and altered their use of Gore-Tex mesh [17].

The recent concern about synthetic mesh has increased the appeal of biologic materials, but they are not without complication. Allograft fascia lata has been described as a biologic alternative to mesh. Increased risk of abdominal hernias after harvesting of the abdominal fascia has been reported [20]. This material precludes the risk of mesh erosion. However, reports of failures associated with attenuation or absence of the fascia lata graft in reoperation [21, 22], presumably secondary to autolysis, have led to decreased use of this material. A retrospective cohort study comparing polypropylene mesh to Pelvicol^® (CR Bard, Murray Hill, NJ, USA) and autologous fascia found a higher rate of failures as well as erosions and other graft-related complications in the Pelvicol group (although it should be noted that Pelvicol was used more frequently in patients undergoing concomitant hysterectomy) [23]. Similar findings of high rates of graft-related complications and unacceptable failure rates were found with porcine grafts [24]. In a randomized trial of 100 women who underwent ASC and were randomized to cadaveric fascia lata vs. polypropolene mesh with a 5-year follow-up, anatomic success was considered greater in the mesh group (93% vs. 62%) and there was no difference in success of patient symptom improvement (97% vs. 90%) [20].

A modifiable risk factor for erosion after ASC identified by the CARE trial analysis was tobacco use [17]. In their group of 322 patients, smoking was associated with a fivefold increased risk of erosion . A retrospective study of 499 patients undergoing ASC found a nonsignificant trend of smokers requiring more than one surgery for effective treatment of vaginal mesh erosion [25]. The dominant theory is that microvascular vasospasm with associated hypoxia may lead to poor wound healing and vaginal mesh erosion in smokers [18].

Approach and technique affect mesh erosion rates. If graft or suture is introduced through the vagina in sacral colpoperineopexy, erosion rates are increased. In a retrospective review of 273 patients, there was no statistically significant difference in mesh erosion rates for patients undergoing ASC (3.2%) or purely abdominal sacral colpoperineopexy (4.5%). In patients undergoing sacral colpoperineopexy with vaginal introduction of mesh or sutures, the erosion rates increased to 16% (vaginal placement of sutures) and 40% (vaginal mesh), which maintained statistical significance on multivariate analysis. These patients exhibited a shorter time to mesh erosion as well, with median time to erosion 15.6 months for ASC, 12.4 months for abdominal sacral colpoperineopexy, 9.0 months in the suture group (P < 0.005), and 4.1 months in the vaginal mesh group (P < 0.0001) [26].

The role of concomitant hysterectomy in mesh erosion after ASC has been debated. In the CARE subanalysis [18], concurrent abdominal hysterectomy was performed in 26% of the patients, who incurred a 14% risk of erosion as compared to 4% in women who had undergone prior hysterectomy. This represented a fivefold increased risk of erosion. Culligan and colleagues found a statistically significant increase in erosion rates in patients undergoing concomitant hysterectomy in a retrospective review of 245 patients (27.3% erosion in those undergoing hysterectomy, 1.3% erosion without hysterectomy) [27]. A retrospective review of 313 patients found a statistically significant fivefold risk of mesh erosion in women on estrogen with concomitant hysterectomy [28]. Of note, they found no significant difference in erosion rates in those undergoing concurrent hysterectomy in the non-estrogen group, or in the overall group as well. These data imply that either estrogen or hysterectomy may increase erosion rates. In our experience, it seems hysterectomy would be the most likely risk factor. In contrast, in a retrospective review of 124 patients undergoing ASC (60 with hysterectomy and 64 without), Brizzolara and Pillai-Allen found a low overall mesh erosion rate of 0.8% and no significant difference in mesh erosions in the hysterectomy group [15]. They attributed their success to two-layer closure of the cuff, careful handling of tissues, and use of antibiotic irrigation [15]. Based on these findings, if a small vaginal laceration is encountered during colpopexy, we close the laceration in two layers as described in the previous study. In reviewing outcomes of colpopexy following hysterectomy, the significance of the CARE subanalysis, as opposed to retrospective reviews, is that it was prospectively designed to capture complications, including mesh and suture erosions, at regular study intervals in the first 2 years. The CARE trial has since extended its analysis and has found the complication of mesh extrusion continues long-term up to 10.5% at 7 years [29].

In cases of mesh erosion after combined hysterectomy and ASC, the erosion site is usually at the cuff. This may be secondary to potential vaginal bacterial contamination of the mesh from the opened vagina during hysterectomy. Alternatively, poor healing may occur at the cuff secondary to a devascularizing effect of cuff closure combined with mesh vaginal attachment sutures [18]. Some authors advocate supra-cervical hysterectomy as an alternative to total hysterectomy at the time of ASC [16]. Currently, the practice of concomitant hysterectomy and ASC remains controversial.

In cases of erosion of Type I mesh (Dacron^®; Marlex^®; Prolene^® [Ethicon, Johnson & Johnson, Somerville, NJ, USA]), treatment with antibiotics and trimming and covering of the mesh is sufficient [14]. Because of the macroporous nature of the mesh, it is expected that macrophages will pass, making complete removal of the graft unnecessary. Additionally, eroded Type III mesh (combinations of multifilament and macroporous components: Teflon, Mersilene) may be treated with partial removal and reclosure of vaginal flaps [14]. However, infected Type II mesh (microporous material: Gore-Tex) must almost always be removed completely, as its microporous nature creates a bacterial sanctuary where access to antibiotics and the immune response is reduced [14, 18].

Conservative therapy with observation and topical estrogen may be initially attempted in small mesh erosions of type I or III mesh (<1 cm). Local excision of mesh is utilized as first line therapy as well, or in cases of failed conservative therapy. In a series of vaginal erosions of Ethibond^® (Ethicon, Somerville, NJ, USA) suture and Marlex and Mersilene mesh, patients presented at an average of 14 months postoperatively (range 4–24). All patients were initially treated with vaginal estrogen and 8 weeks of pelvic rest. Two patients with suture erosions resolved with this regimen, but all five patients with mesh erosion required surgical intervention and were successfully treated with vaginal mesh excision and flap advancement [13]. In another series, local surgical excision of exposed mesh carried a reported efficacy rate of 50% [25]. If the upper portion of the mesh is infected, it must be removed [18]. In the CARE subanalysis, 6% of patients experienced mesh/suture erosion. Most of the women with mesh erosion (13/17) underwent at least one surgery for partial or total mesh removal. Two patients completely resolved, six had persistent problems, and five were lost to follow-up [18]. Of the four women who elected observation , none experienced resolution [18].

Well-circumscribed areas of mesh extrusion may be approached vaginally. We excise only the exposed area with an additional margin of 1–2 cm; not all of the mesh needs to be excised. Surgical exposure of apical mesh extrusions in the post-sacrocolpopexy patient is more challenging than in distal vaginal extrusions. When the apex is well supported, it may be difficult to pull the apex into the forefront of the surgical field. We use a Lone Star^® retractor (Cooper Surgical, Trumbull, CT, USA) with sharp hooks placed proximal to the mesh to expose as well as possible. Hydrodissection may be utilized around the area of the extrusion. We grasp the edge of the vaginal margin and dissect laterally between the vaginal margin and the mesh with Metzenbaum scissors to create vaginal flaps that extend about 2 cm circumferentially. If the edge of the mesh is available, we grasp that edge and begin our dissection underneath the mesh. If an edge is not accessible, we incise the mesh and isolate each resultant edge in an Allis clamp. Oftentimes, the mesh will peel off the underlying tissue with a combination of blunt and sharp dissection. We keep the scissor tips pointing toward the mesh. Once the mesh has been separated back to the edges of the initial dissection we inspect the quality of the edges of our vaginal margins. If there is any question about the quality of the tissue, we will excise or debride the edges. Finally, we re-approximate the vaginal flaps with absorbable suture in a tension-free closure with no mesh under the suture line. Other authors have advocated a partial colpocleisis type approach [25]. If the initial extrusion is extensive or if prior vaginal approaches have failed, an abdominal approach may be attempted. Abdominal excisions are associated with higher blood loss, longer hospitalization, and additional morbidity [25].

In all cases, the approach to extrusions is vaginal unless there is other intra-abdominal pathology warranting correction. In an abdominal approach, extensive scarring and adhesions will be encountered. A full bowel preparation is recommended and vaginal localization can be assisted with the use of an EEA sizer and or a Lucite vaginal stent. Partial removal of offending mesh is acceptable unless gross infection is present. The vaginal defect should be repaired in two layers using absorbable sutures. In cases of poor tissue quality, a biologic interposition over the vaginal cuff or omentum may be utilized to assist in cuff healing .

Patients with mesh erosion into the bladder after ASC may present with hematuria, irritative voiding symptoms, recurrent urinary tract infections, or chronic bladder stones. Diagnosis of this problem hinges on a high index of suspicion and a low threshold to perform cystoscopy . Maintaining a full thickness of the bladder without cystotomy during dissection, or alternatively, minimizing bladder mobilization may help in avoiding this complication.

Patsner reported a case of erosion of polypropylene mesh and Prolene suture into the bladder base presenting 4 months after ASC who was treated with open excision after two failed cystoscopic attempts [30]. Shepherd and coworkers performed a retrospective cohort study over 10 years looking at the mesh/suture erosion rate based on type of suture. Mesh suture exposure rate was found to vary with type of suture, 3.7% with Ethibond and 0% with PDS [31]. Yamamoto and coworkers report a vesicovaginal fistula after abdominal hysterectomy and ASC which occurred adjacent to the edge of the mesh and required abdominal repair [9]. In our experience, we have not had a mesh or suture erosion into the bladder secondary to ASC (Fig. 9.4). To reduce risk of suture erosion into the bladder, we now use PDS suture to fixate the graft to the vagina. Depending on the site of erosion and the amount of mesh, a cystoscopic approach may be attempted. If this fails or is precluded by position or mesh volume, an open cystorrhaphy may be necessary. If the mesh is near the ureteral orifice, the surgeon should consider a retrograde pyelogram or a ureteral stent to delineate the ureter. In a retrospective review of intravesical mesh management cases (from various causes), Frenkl and coworkers concluded that, in their experience, sutures were managed most successfully with endoscopic techniques, where mesh was best managed with cystorrhaphy [32].