WHAT A MESH! A RADIOLOGIST`S GUIDE TO MR IMAGING OF

WHAT A MESH! A RADIOLOGIST’S GUIDE TO MR IMAGING OF PELVIC FLOOR SURGICAL REPAIR
Elizabeth Furey MD1, Gaurav Khatri MD1, April Bailey MD1, Maude Carmel MD2 , Philippe Zimmern MD2 , Ivan Pedrosa MD1
Departments of 1Radiology and 2Urology, UT Southwestern Medical Center, Dallas, TX
PURPOSE
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• To illustrate magnetic resonance imaging (MRI) findings of various
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pelvic floor repair procedures including different types of urethral
slings and vaginal mesh products.
BACKGROUND
• Pelvic floor disorders including pelvic organ prolapse (POP),
chronic pelvic pain, defecatory dysfunction, and urinary and fecal
incontinence affect nearly 1 in 4 women in the US1.
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e
• >300,000 procedures performed annually in US for POP alone2.
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Fig 6. 56Yo female with prior rectocele repair with mesh,
presenting with left posterior vaginal wall tenderness. Axial T2W
TSE images demonstrate normal hypointense ribbon-like thin
right sided arm of posterior vaginal wall mesh (orange arrows),
however the left arm (yellow arrows) is thickened particularly
along the vaginal wall (green arrow). Focal thickening may
suggest exuberant scarring or complications such as extrusion.
Endoscopic examination confirmed mesh extrusion.
• Surgical options: native tissue repair, urethral bulking agent
injection, repair with biologic/absorbable materials or synthetic
materials.
• Potential surgical complications: dyspareunia, chronic pain,
extrusion, or recurrent infection.
• Imaging may help detect synthetic materials and associated
complications.
• This review is intended to guide the radiologist in interpretation of
these challenging post-operative cases.
SURGICAL OPTIONS
Stress Urinary
Incontinence (SUI)
Pelvic Organ Prolapse
(POP)
Mid-urethral Sling procedures
Native Tissue Repair
Retropubic (RP) Slings
Biologic/absorbable Graft
Transobturator Tape (TOT)
Synthetic Vaginal Mesh
Single Incision Sling (Mini-sling)
Mesh Sacral Colpopexy
Fig 2. 47YO female with vaginal mesh and RP sling. Axial
T2Weighted (T2W) Turbo Spin Echo (TSE) images (a-d) demonstrate
the sling as a “U-shaped” hypointense curvilinear structure in
the peri urethral and RP spaces (blue arrows). The sling is seen
traversing the rectus fascia on the left (blue arrows). Posterior
vaginal mesh is visualized as a dark band along the anterior rectum,
with the arms traversing the levator muscles and ischiorectal fossae
(orange arrows). Coronal T2W TSE image (e) in a 49YO female
with RP sling and vaginal mesh demonstrates slit-like on end
appearance of the sling in the RP space (blue arrows), while the
sagittal T2W TSE image (f) demonstrates linear appearance in the
RP space (blue arrows). Anterior and posterior vaginal wall mesh is
also seen on the sagittal image (orange arrows).
Transobturator Tape (TOT) (Fig 3a, 4) )
muscles without violating retropubic space.
• More difficult to visualize on MRI than RP slings.
• Lower rate of bladder injuries and voiding difficulties vs. RP
Retropubic (RP) Slings
slings; higher likelihood for groin pain, vaginal injury, and mesh
extrusion3.
• Original ‘outside-in’ (OI) technique - trocars passed into obturator
foramen percutaneously and then through previously made
midline vaginal incision4.
Advantage FitTM Transvaginal MidUrethral Sling System
• ‘U’-shaped sling around mid urethra
- arms extend anterosuperiorly into
retropubic space.
E.g. Monarc™ (AMS, Minnetonka, MN); ObTape* (MentorPorges, Le Plessis Robinson, France). *Off the market due to high
rate of vaginal extrusion and serious infectious complications .
• Potential complications: bladder
5
perforation or blood loss/vascular
injury3.
• Variant ‘Inside-out’ (IO) technique - sling placed via midline
vaginal incision and then through obturator foramen using
specialized instruments6.
http://www.bostonscientific.com
(9/19/2014)
1. Transvaginal approach- Tension-free
▪▪ Most widely used RP sling.
▪▪ Trocars passed via vaginal incision into retropubic space
foramen; do not course into foramen.
• Lower theoretical risk of organ, nerve and muscle injury during
and through suprapubic rectus fascia, 2.5 cm lateral to
pubic symphysis, on either side of midline.
placement.
• Less post-operative pain vs. IO TOT, but higher risk of vaginal
2. Suprapubic approach- Suprapubic Arch sling (SPARC™, American
▪▪ Similar to TVT, however placed “top-down” via
▪▪ Arms of sling are approximately 1cm lateral to pubic
*Off the market.
symphysis on either side of midline.
Pubic
symphysis
Pubic
symphysis
Sling
b
Pubic
symphysis
Sling
Urethra
Urethra
Urethra
Obturator
Foramen
Sagittal
Midline
Pubic
symphysis
Sling
Urethra
Obturator
Foramen
Vagina
Vagina
Vagina
Rectum
Rectum
Rectum
Vagina
Fig 1. Illustrations in the axial plane demonstrate expected
location of TVT (a) and suprapubic approach slings (b)
relative to the pubic symphysis, urethra, and vagina.
extrusion rate up to 18%; higher reoperation rate9.
• Higher rate of bladder perforation, increased blood loss, longer
operating time, de novo stress incontinence (Prolift®* vs. anterior
colporrhaphy )10.
• Other complications: recurrent or chronic infection, pain,
dyspareunia.
E.g. Apogee™/Perigee™ (AMS, Minnetonka, MN); Avaulta® (C.R.
Bard, Inc., Covington, GA); Gynecare Prolift®* (Ethicon, Bridgewater,
NJ); Elevate™ (AMS, Minnetonka, MN); Pinnacle®, Uphold™ (Boston
Scientific, Marlborough, MA). *Off the market.
Elevate® Anterior and Apical
Prolapse Repair System
• Mesh placed from sacral
promontory to vaginal apex in
‘upside-down “Y” configuration’.
Usually rightward curvature from
superior to inferior.
Sling
Fig 3. Illustrations in the axial plane demonstrate expected
location of TOT (a) and single incision slings (b) relative to the
pubic symphysis, urethra, vagina, and obturator foramina.
Upsylon™ Y-Mesh and Colpassist™
Vaginal Positioning Device
Pinnacle® Posterior Pelvic
Floor Repair Kit
Avaulta Solo® Graft
Anterior
http://www.bostonscientific.com
(9/19/2014)
Fig 5. 3D illustration
of a vaginal mesh
kit demonstrates
components of the
mesh anterior and
posterior to the vagina.
Arms from the anterior
vaginal mesh extend
into the obturator
foramen. The posterior
arms traverse the
sacrospinous ligament.
Sacrospinous
Ligaments
Posterior arm
Posterior
arm
Anteror arms
Anteror arms
Sagittal
▪▪ Look for hypointense linear/curvilinear structures on T2W
images.
rectus fascia).
• TOT/Mini-Slings – periurethral, obturator foramen.
• Vaginal Mesh – anterior/posterior vaginal wall,
rectovaginal space, arms traversing C-SSL or levator
muscles into obturator foramen and/or ischiorectal fossa.
• SC mesh – sacral promontory to vaginal apex.
PELVIC MESH MRI PROTOCOL
Sequence
appearances of various urethral slings and pelvic mesh kits/
products.
• RP Slings – periurethral, retropubic, suprapubic (traversing
vaginal mesh kits (8-20%)8.
Imaging
Plane
• Radiologists should be aware of the expected locations and
▪▪ Check particular brand of synthetic product.
• Variable extension of mesh
• Lower rate of vaginal erosion/extrusion (3-5%) compared with
http://www.bardmedical.com
(9/19/2014)
• Various surgical options exist for repair of pelvic floor dysfunction.
• Radiologist checklist:
transvaginal mesh, but longer operative time, longer time to
return to activities of daily living if performed via transabdominal
approach9.
http://www.bostonscientificinternational.com (9/19/2014)
SUMMARY
complications such as chronic pain, infection, extrusion, etc.
Sacral Colpopexy (SC) (Fig. 8)
• Superior outcomes vs. sacrospinous or uterosacral fixation, and
http://www.amselevate.com
(9/19/2014)
Fig 8. Sagittal illustration (a) demonstrates expected course of
SC mesh from sacral promontory to the vaginal apex. Sagittal
T2W TSE image (b) in a 63 YO female with SC mesh demonstrates
normal appearance of the mesh (orange arrows). Extension along
the posterior vaginal wall is seen on this image (green arrow).
COR T2W TSE image (c) in a 69YO female with suspected recurrent
enterocele post SC mesh shows normal caliber and expected
rightward curvature of the mesh (orange arrows). Sagittal T2W
TSE image (d) in a 73YO female with clinical mesh erosion and
foul smelling vaginal discharge demonstrates abnormal signal
surrounding a markedly thickened SC mesh (yellow arrows).
Purulent drainage was confirmed at surgery.
• Patients with prior synthetic repair may present with various
components along anterior and
posterior vaginal walls; posterior
extent typically longer.
Uphold® Vaginal
Support System
http://www.bostonscientific.com
(9/19/2014)
Sagittal
Midline
1 cm
2.5 cm
• Lower recurrent prolapse vs. native tissue repair, but mesh
Fig 7. 49YO female with RP sling and anterior and posterior vaginal
mesh. Axial T2W TSE image (a) demonstrates redundant linear
hypointense signal intensity bands along the anterior and posterior
vaginal wall (orange arrows), thought to represent mesh and scar
tissue. Arms of the RP sling are seen deep to the rectus abdominis
(blue arrows). Coronal T2W TSE images (b, c) demonstrate the arms
of vaginal mesh extending laterally through the levator muscles
and then coursing in craniocaudad direction through the obturator
foramen (orange arrows).
2D T2 TSE
a
Sagittal
Midline
tendineus (AT), coccygeus muscle-sacrospinous ligament complex
(C-SSL), obturator membrane, and levator and inner thigh
muscles8.
E.g.- MiniArc™ (AMS, Minnetonla, MN); Ajust (C.R. Bard, Inc.,
Covington, GA); TVT™-Secur* (Gynecare, Ethicon, Bridgewater, NJ).
suprapubic approach of trocars into retropubic space3.
b
Synthetic Vaginal Mesh (Fig. 2, 6, 7)
exposure, bladder/urethral extrusion, and operative blood loss
(TVT™-Secur*)7.
Medical Systems [AMS], Inc., Minnetonka, MN) (Fig. 1b)
Sagittal
Midline
E.g. vaginal colporrhaphy for anterior or posterior prolapse;
sacrospinous ligament fixation or uterosacral ligament suspension
for apical prolapse.
• Similar to TOT, however arms of sling terminate at obturator
▪▪ Arms of sling course between bladder and pubic bone,
a
• Primary repair of native tissues +/- biologic grafts.
Single Incision Sling (Mini-sling) (Fig 3b)
and then to ventral abdominal wall (“bottom-up”)3.
c
b
Native Tissue Repair
E.g. TVT™ Obturator System (Gynecare, Ethicon,
Bridgewater, NJ).
vaginal tape (TVT™, Gynecare, Ethicon, Bridgewater, NJ) (Fig. 1a, 2)
a
PELVIC ORGAN PROLAPSE
• Provide anterior and/or posterior support by anchoring to arcus
• Transmuscular insertion through obturator and puborectalis
STRESS URINARY INCONTINENCE (SUI)
Mid-urethral Sling procedures
Fig 4. 64YO female with worsening incontinence, bilateral groin
and thigh pain since TOT placement. Axial T2W TSE images
demonstrate periurethral hypointense bands traversing the
levator muscles and extending into the obturator foramen
bilaterally which could represent urethral tape or scarring (blue
arrows). More inferiorly, distal arms of the sling are better seen
on-end coursing between the obturator muscles (green arrows).
Slice
thickness/
gap (mm)
FOV
(cm)
4/0.4
20
▪▪ Differentiating scar from mesh or tape may be difficult.
REFERENCES
1. Nygaard I, Barber MD, et al. Prevalence of symptomatic pelvic floor disorders in US women.
JAMA : The journal of the American Medical Association. 2008;300:1311-6.
2. Shah AD, Kohli N, et al. The age distribution, rates, and types of surgery for pelvic organ
prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:421-8.
3. Roth CC, Winters JC, Woodruff AJ. What’s new in slings: an update on midurethral slings. Current
opinion in urology. 2007;17:242-7.
2D T2 TSE Fat
suppressed
Sagittal
2D T2 TSE
Coronal
4/0.4
18
4. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of
stress urinary incontinence in women]. Progres en urologie : journal de l’Association francaise
d’urologie et de la Societe francaise d’urologie. 2001;11:1306-13.
2D T2 TSE
Axial
4/0.4
18
5. Yamada BS, Govier FE, et al. High rate of vaginal erosions associated with the mentor ObTape.
The Journal of urology. 2006;176:651-4.
3D T2 TSE
Axial
1.0(isotropic)
18
6. de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence:
transobturator vaginal tape inside-out. European urology. 2003;44:724-30.
2D T1 IP/OP
Axial
5/1
18
3D SPGR pre- and
dynamic postcontrast
Axial
3/1.5
24
4/0.4
20
Footnote: TSE-Turbo Spine Echo; IP/OP- In phase/opposed phase; FOV-Field of View;
SPGR-Spoiled Gradient Echo.
7. Nambiar A, Cody JD, Jeffery ST. Single-incision sling operations for urinary incontinence in
women. The Cochrane database of systematic reviews. 2014;6:CD008709.
8. Nitti VW. Vaginal Surgery for the Urologist. Philadelphia, PA: Elsevier Saunders; 2012.
9. Maher C, Feiner B, et al. Surgical management of pelvic organ prolapse in women. The Cochrane
database of systematic reviews. 2013;4:CD004014.
10. Altman D, Vayrynen T, et al. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ
prolapse. The New England journal of medicine. 2011;364:1826-36.