Estelle Finds Complete TVT Removal

Estelle Tasz Hugs Dr. V

"Estelle Tasz, 38, sat on the plane heading to St. Louis for her second pelvic mesh removal in as many months. She had surgery one month earlier at the University of California Los Angeles (UCLA) for removal of her transvaginal mesh, a TVT retropubic sling made by Ethicon (Johnson & Johnson). However, one hour after she was put under, she was out of surgery.

Estelle said it never felt like she even had surgery because she still felt the pain from mesh inside her pelvis. UCLA had not been able to remove all of her polypropylene mesh. Having undergone four removal surgeries in the past, Estelle, who is a nurse, says the surgery provided her little, if any, relief.

Read background story on UCLA trip here.

On the first leg of her flight to St. Louis Estelle sat next to an older man named “Nate.” Was she traveling for business she was asked? “I’m a talker,” she says and Estelle volunteered she was traveling to a hospital in St. Louis to have plastic pelvic mesh removed. Ironically, Nate said his 88-year-old Aunt Estelle had had a mesh sling and hadn’t done well with it for as long as he could remember. Aunt Estelle had undergone 22 surgeries and was in a wheelchair still fighting.

He remembered her always being in the hospital.

“When little kids ask, ‘When will she be back,’” Nate said, “just tell them every minute she’s away is a closer minute she’ll be back. Tell your children that it got me through a lot.”

His whole thing was we are fighting the same fight, though not in the same way.

Estelle says she handed him one of her small wallets to give as gift to his daughter. Nate helped her down the ramp to catch the next leg of her flight. He handed her his ticket so she’d remember the time and date they met. “He was so genuine. I’ll never forget Nate,” said Estelle.

Nate provided his email and told her to stay in touch, even though he knew how the story would end. “I know you’re going to go on to great things,” he told Estelle.

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For what she hoped would be her final mesh removal she chose Dr. Dionysios Veronikis at the Vaginal and Urogynecology Institute at Mercy Hospital in St. Louis.

A few days prior, Estelle had met Dr. Veronikis for the first time and after several phone conversations she felt confident in his abilities. Mercy Hospital has a growing mesh removal section and Dr. Veronikis and Dr. Sara Wood are now seeing ten to 20 patients a week with about 65 percent of the patients being seen for mesh removal.

Pelvic mesh is routinely used to shore up pelvic organs that drop, sometimes through the vagina, due to childbirth, pregnancy, aging and weakened pelvic floor muscles. The mesh used is generally polypropylene, a polymer product, and it is placed under the urethra for support to help with urinary incontinence or in the pelvic floor to treat pelvic organ prolapse.

Tasz mesh

On Tuesday August 5th, Estelle underwent her 4.5 hour surgery. Dr. V retrieved the remaining 17 centimeters of mesh. He showed her the image. The mesh had the familiar blue color through it.

Estelle at UCLA

“Finally I was told the truth” she says. Finally I met a doctor who cares, who is a doctor by all meanings of that definition.”~ Estelle Tasz

Complete TVT Removal: Vaginal and Abdominal Incisions

Akre and Veronikis

I wanted to travel to St. Louis to understand what Dr. V did differently from other mesh removal doctors and to get a full appreciation of the different types of mesh and how they are placed. The graphic surgical still shots don’t always tell the picture to the average viewer.

Dr. Veronikis explains in his new website here.

“You cannot have a full TVT removal without an abdominal cut. Absolutely” he says.

“Dr. V” as he’s known, is a sub-specialist in gynecologic and reconstructive surgery at the Vaginal Surgery and Urogynecology Institute at Mercy Hospital St. Louis, Missouri.

TVT and TVT-O, surology.com

The surgeon firmly believes transvaginal tape (TVT) removal must be addressed through both a vaginal incision as well as abdominal where the mesh is anchored to the abdominal muscles, fascia and tissue under the skin.

TVT differs from a TOT implant (transobturator tape) which runs laterally and exits through the obturator space.

He insists it is the only way to do a complete TVT removal he says. Anything less likely leaves behind the mesh arms anchored in the abdominal wall and retropubic tissues.

Though a tedious and meticulous procedure, he locates the mesh, first through an incision in the vagina. Working in rotation, he carefully frees the tissue around the mesh, uses fine scissors to cut and slightly tugs the mesh to free it. It is a slow, meticulous process working up each side of the mesh, which has been freed from under the urethra where it was originally placed to treat urinary incontinence.

TVT removal, Dr. V. website

One side then the other, working up as far as one can safety travel up past the urethra and into the retropubic space, the space behind the public bone. Then, through the abdomen he starts working down from where the mesh exits again in a rotation of procedures, using cautery and a refined scissor technique as well as a gentle tug working down the mesh toward where he has already been freed in the vagina.

The goal is to meet somewhere in the middle.

Dr. V. has produced a series of videotapes showing the technique to be used to teach others, and to educate the patient. At one point in the video which he showed me, the mesh actually had been freed to the point when it actually pops out of the abdominal space with a slight tug.

Incorrectly referred to as a “tummy tuck,” it actually is performed to make surgery easier and to rid of the pannus or a hanging flap of skin that has been previously sliced during a C-section or a hysterectomy. The doctor attaches the top skin of the abdominal cut to the bottom skin which has been removed in a slight smile. That way any dead skin from previous procedures as well as excess tissue can be eliminated making the surgical area less prone to infection.

Akre and Tasz, St. Louis

The procedure is different from a true tummy tuck performed by a plastic surgeon in that no liposuction is performed; there is no procedure under the rib cage and no relocation of the belly button.

The visit to St. Louis allowed me to visit Mercy Hospital, see Dr. Veronikis’ mesh training videos and accompany Estelle who needed help traveling. Not only did I receive a lesson in the different types of mesh implants, instruction on the retropubic space as well as the obturator space, but I also got a lesson in the history of incontinence treatment over the last century.

Dr. Veronikis, who was trained at Harvard, believes this is the “darkest chapter” in female pelvic health treatment.

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PART TWO CONTINUES HERE:

A story does not imply an endorsement or medical advice. Please consult with your medical professionals concerning your personal care. ~ ja

Continued from Part One

Dr. Dionysios K. Veronikis, M.D. is a specialist in vaginal surgery and urogynecology who trained at Massachusetts General Hospital, Harvard Medical School in Boston. He heads the Vaginal Surgery and Urogynecology Institute at Mercy Hospital in St. Louis where he and his surgical partner, Dr. Sara Wood, perform 10 to 20 pelvic surgeries a week with more than half of the procedures for mesh removal. They are among a handful of known mesh removal specialists to handle the hundreds of thousands of women who need pelvic surgery following the implantation of polypropylene mesh to treat the common problems of incontinence and prolapse in women after having children.

Despite four previous attempts to remove the polypropylene mesh, patient Estelle Tasz, 38, knew her transvaginal tape (TVT), made by Ethicon, had not been totally removed. The trained nurse still felt the plastic mesh that she’d received to treat her incontinence. She chose “Dr. V” as she calls him for what she hoped would be her final complete mesh removal.

Estelle Tasz at J&J headquarters, April 2014

She made the trip to St. Louis and I arrived the day after her surgery help Estelle get home and to learn about the different types of mesh used in women and their placement. It was only truly made clear with a 3-D plastic model of the pelvis and through watching mesh removal videos which are now online on a website Dr. V has just established.

See it here:

Darkest Chapter

Dr. V had called mesh the “darkest chapter” in gynecological history. Something that was supposed to treat the conditions of incontinence and prolapse in women, common after childbirth, have actually made things worse for women, he says.

He particularly dislikes mesh kits and TVT-O named for passing the arms of the mesh through the obturator space and into leg muscle and possibly nerves.

“Mesh prolapse kits were just a bad idea. I don’t know why so many went down that road. With all of those mesh arms and a massive amount of mesh and the one size fits all approach. Every woman is different,” he says. Dr. V believes they are defectively designed.

Abdominal Cut

He explains and insists “You cannot have a full retropubic TVT sling removal without an abdominal cut.”

“You cannot remove the entire retropubic TVT sling mesh with only a vaginal approach and you cannot remove TOT (transobturator tape) without groin incisions. When I am trying to get all of the plastic mesh out, I need to make an incision at the mesh exit sites or I am cheating women from getting a full removal of the mesh.”

To get all of the mesh out, Dr. V states the only way to proceed is vaginally and abdominally for a retropubic sling. To remove mesh one must start the removal the way the mesh went in, that is vaginally. If you have a mesh exit site out of the skin you have to make an incision at the exit site to remove that portion of the mesh. It’s common sense, he says.

Dr. V talked to Mesh News Desk editor, Jane Akre

“If a women has a vaginal mesh erosion, that can be addressed with removal from the vaginal site with a partial removal. You educate the patient and counsel them; offer options and let them decide what is best for them and then give them what they choose.

“Some women will ask, ‘Do I need that abdominal portion removed?’ I say not to treat the erosion which is in the vagina but that does not remove the entire mesh. As long as you’re honest, you proceed. Have I removed every TVT sling abdominally? No, because a patient says they just want the eroded part removed, they want to leave the rest alone.

“The next question is can you go back later and get it? Absolutely, you can do a removal at two different times.

“I do feel differently about mesh prolapse kits and this is where the partial removals become a surgical challenge with the multiple arms. With mesh kits I absolutely advocate total removal of the mesh over the rectum or under the bladder with the arms at one time.”

Are you saying most mesh removals are not complete unless there is an abdominal incision? - “Correct. To completely remove TVT and TOT slings, one must make additional incisions at the exit sites, the abdomen for TVT, the groin for TVT-O. Prolapse mesh kits are not in this category. They can be removed from a pure vaginal approach. If a patient is wondering how much mesh was removed, she can obtain her pathology report and add up the pieces. Hopefully, the pathologist measured each individual piece, sometimes they don’t know to do that. Pathologists weren’t measuring every piece. Add the length together. Although all women are different, look for 18-22 centimeters for TOT mesh depending on the woman’s pelvis and for TVT removal maybe 24-30 centimeters for a TVT retropubic sling. A larger woman will have more mesh.”

We know carrying children and giving birth is one factor that contributes to prolapse so are women with C-Sections are spared? - “Those women almost invariably their pelvic floor is spared they don’t have incontinence, pelvic floor prolapse unless they are habitual straining. Childbirth is not the only trauma. Living longer, asthma, constipation, heavy lifting all contribute to pelvic floor prolapse.”

You don’t routinely use ultrasound - why not? - “If the mesh implant is intact, or intact and eroded and even visible on exam you totally don’t need ultrasound. How does it really help you? Perhaps to confirm that mesh is left after partial removals. OK. However, it does not assist you in the OR. It may point you in the right direction for exploration. Will the ultrasound see all the mesh? Could it miss some? I rely heavily on clinical parameters, previous operative reports, sometimes the implant log, using clinical exam and the patients’ pain as well as her symptoms.

“Invariably, at surgery, I make sure I double check during a mesh removal that I have removed all that I can remove instead of having the mindset that I can return in the future for another mesh removal. The only person I could not find mesh in had a TVT Abbrevo implant, who had previous mesh removal, who also had an ultrasound. Ideally, if you could do surgery and while doing surgery you could simultaneously ultrasound the surgical field to look for mesh, well, now you are going beyond surgery. That would be wonderful.”

What about a patient who’s been diced and sliced after a dozen removal attempts? - “There is a patient who had 22 surgeries and I still got her mesh arms out because she still had some mesh remaining. I'm not sure ultrasound would have penetrated well that deep in her pelvis, we are talking 10 or more centimeters to reach that depth of her mesh arm.”

With that many surgeries how can someone say that's not scar tissue? - “Sure, that can be a very tough call. One may over call it to avoid under calling the diagnosis. In the OR,all I need is one mesh thread. If I see one thread I’m on it."

To what do you owe your success with mesh removal? - "It has to do with being a vaginal surgeon, not just being a gynecologist, a urologist or a urogynecologist or someone who specializes in laparoscopic or robotic surgery. You need a subset of specialists who are vaginal surgeons.”

Why not use imaging as insurance? - “One can, but mesh doesn’t migrate. Mesh doesn’t have legs, they don’t walk and there is no fluid to push it. It’s right there. It’s not going to migrate. All my mesh removal pictures are without the use of ultrasound.”

Can’t scar tissue cause mesh to shrink? - “Yes, that will cause mesh to shrink which is why you don’t want a mesh product that is too stiff you want to it flex and bend a bit. It’s like an empty tractor trailer. If you have ever seen an empty one next to you on the highway, it has a convex curve to it, but when you put load on it it’s designed to flatten out. Therefore, all implants are designed to behave a certain way with “load”, stress placed on the body. Even native transplanted tissues that have a perfect function in one part of the body, will not behave the same when transplanted. Take skin for example, it starts to shrink the second it is removed due to inherent interruption in the continuity of the elastic fibers.”

Do you agree with the reclassification of pop mesh into class III? - "Yes. I don’t think mesh kits should be on the market, as a surgeon I’d like to have the availability to be able to use it with proper counseling of the risks versus benefits. Now if there was something better let’s bring it on. However,you can’t fix these defects in some women without implants and an option is mesh.”

What about TVT-O? It was found defective in a courtroom? - “I think the procedure is defective. I don’t think we should go into the obturator muscle and leg muscles. No one does a fascia lata sling, abdominal fascia sling or cadaveric fascia sling going in the obturator. There’s never been a single report of a TVT-O sling done with fascia, why? The TVT-O is a different concept it goes under the urethra and laterally flares out. It’s approach exits the pelvis and unites two different organ systems.”

See the history of TVT-O developed in 1907 by von Giordano around the urethra (here).

The history of slings (here):

Is there a single solution for mesh removal? (here)

The TVT mesh you still use. Why? – “ I do surgery and I use implants to treat a condition and improve a woman’s quality of life. The patients in our practice do not experience mesh-related complications. Furthermore, if they should, I will be attentive and able to help resolve them and not dismiss them.

“ Of all these meshes, all these products are different, not just procedurally, but the materials are different. Perhaps the best way to describe this is that I do surgery and regardless of the implant, I prep my implant site exactly the same. If a different product was out there with uniform reliable behavior and results, for the way we do surgery, it would be simple exchange from one implant to the other. Mesh slings provide the best most durable and uniform product with reproducible results.”

What about autoimmune issues? Many women seem to be high reactors to mesh and are diagnosed with fibromyalgia, rashes even Lupus after their mesh implant? Could that be just a correlation? There seem to be too not to see causation. - “I do ask questions about fibromyalgia and lupus and a fair number have it before surgery. Is it that this inciting event really makes that a lot more noticeable? Perhaps. I'm acutely aware this is now on my radar and I keep looking.”

Do you have the ability to follow-up and determine if these autoimmune conditions improve some time after a complete explant? - "Yes, I had a patient that was referred for mesh removal that had a severe reaction to a Bard Adjust sling and all her symptoms resolved."

Many women report bacterial staph infections that are antibiotic resistant. They show pictures of their rashes breaking out all over their bodies. Are you keeping explanted mesh so it can be studied for chemical additives, polymer degradation? - “My policy is to send every mesh explant to pathology. I'm reading the literature. The meshes are so different, so you really need to do proper test and analysis before it goes in and when it comes out. You have to use the same mesh comparing it to non-implanted mesh. You can’t compare a J&J TVT to the AMS Sparc mesh. You have to make these comparisons - the weight of the mesh, where was it made, manufacturing process? It’s on my radar. We don’t want to be hurting women we want to improve their quality of life."

With TVT your adverse events, did you say were less than one percent? - “They are less than that. Some women cannot empty their bladder completely, but that can happen with a burch procedure. I don’t know, that may be an adverse event of just having surgery. It depends on how you define adverse event. Erosion or extrusion of mesh in the vagina is exceedingly rare. I’ve put in nearly 10,000 slings and maybe there were three or four in 2 pack a day heavy smokers. A bladder perforation that causes a hole in the bladder can happen with a burch, but it’s much more likely to happen with the sling. A poster we presented looking at 1 year of sling data showed a an adverse event bladder perforation rate of .25 percent This translates to maybe one patient in 400 undergoing a sling and the consequence is she goes home with a catheter for five days.”

What about pain as an adverse event? - “ I believe in removing the mesh or the fascial implant or the suspension performed with a suture. For pain, removing the mesh helps the patient, and the faster, the better off they are.”

What if a doctor wants to train with you? - "I'm not inclined at teaching everyone and anyone who says I want learn how to remove mesh. It takes a high degree of dedication.I’ve trained Dr. Wood. It would take someone truly dedicated at least a month by my side to train them to remove mesh. We need a master mesh removal surgeons dedicated to mesh removal and treatment in treatment centers across the country.”

Are you a consultant or preceptor for any mesh maker either now or in the past? – “ I was a preceptor for BARD in 2005 for one year or so teaching retropubic sling only. I have not prior to that or since been a preceptor.”

One of the most important questions is about the cost? I’ve heard a mesh removal surgery can run about $30,000? - “I’m amazed, is that correct? For someone who didn’t have insurance at all I would estimate that at my hospital, for a patient without insurance, all fees with hospital stay for a typical complete removal of TVT would be maybe $10,000. I do 10 to 20 surgeries a week and about 750 surgeries a year, now with 60 to 65% for mesh removal.”

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Back home now, Estelle Tasz says most of her fight is now behind her. She’s heard before she is mesh free but she says this time the pain in her face is going away. “I feel empty but I feel full. It’s the weirdest feeling, it’s gone, it’s gone. I have a full life ahead of me and Dr. V gave me hope. He saved my life, as a mom, I can’t thank him enough for that.” #