V4 - Mesh Infection in Ventral Mesh Rectopexy Requiring Surgical Excision

Image or Table (Do Not add text here):

Purpose/Background: Ventral mesh rectopexy (VMR) is a widely accepted surgical procedure for treatment of rectal prolapse as well as multicompartment pelvis organ prolapse. This procedure can provide significant functional improvements with low recurrence rates. However, mesh infection is a major complication that can lead to significant morbidity. The incidence of mesh infection in VMR ranges from 0.5% to 3% with use of synthetic mesh. Patient-related factors such as obesity, diabetes, smoking, and immunosuppression also increase the risk of postoperative infections. The most common causative pathogens are Staphylococcus aureus, Escherichia coli, and Enterococcus spp., with anaerobic organisms being frequently implicated in colorectal surgeries. The infection can spread from a localized area of mesh contamination to surrounding tissues, leading to pelvic abscess, rectovaginal fistula, chronic pelvic pain and worsening defecatory function. The infection of rectopexy mesh can present acutely with fever, low back pain, urinary retention, vaginal discharge and tenesmus. Symptoms are often more insidious in chronic infection, and usually result from mesh erosion into the rectum or vagina as well as osteomyelitis of sacral promontory. Diagnostic imaging such as CT or MRI, along with endoscopic evaluation, is essential for identifying mesh-related complications. The treatment of mesh infections typically depends on the severity and chronicity of the infection. In cases of superficial or early infections, conservative management with antibiotics and percutaneous drainage can suffice. Deeper or chronic infections involving mesh erosion or fistula formation, surgical intervention is often necessary. This may involve fecal diversion, complete excision of infected mesh, fistula takedown, and reconstructive procedures.

Methods/Interventions: N/A

Results/Outcomes: N/A

Conclusion/Discussion: In this video we present a patient with neurogenic bowel and bladder secondary to syringomyelia who developed vaginal and rectal prolapse due to chronic straining. This patient underwent robotic assisted ventral mesh rectopexy in combination with hysterectomy, mesh sacrocolpopexy and suprapubic catheter placement who presented to clinic with dull low back pain and tenesmus. Patient underwent MRI and CT imaging and was found to have osteomyelitis at S1 vertebral body and loculated fluid collection along the rectopexy and sacrocolpopexy mesh in the rectovaginal septum, concerning for communication with the cervix canal. This fluid was aspirated, and culture showed polymicrobial growth confirming mesh infection. Patient was placed on extended course of IV antibiotics but had no improvement in symptoms and persistence of fluid and inflammation in the rectovaginal septum on follow-up imaging. Patient subsequently underwent robotic assisted excision of rectopexy and sacrocolpopexy mesh, trachelectomy, bilateral oophorectomy and creation of loop colostomy.