Women with complications caused by deeply embedded vaginal mesh are being aided by a pioneering surgical technique.
Fong and two Australian colleagues have recently started a pilot study using robot-assisted surgery to treat women whose vaginal mesh is implanted so deeply into their pelvis that it is very difficult to remove using conventional surgery. Fong has so far used a robot to successfully remove vaginal mesh from three women. She hopes to do another seven or so similar operations to see if robot-assisted surgery can be used to completely remove implanted mesh.
Thousands of New Zealand women have had mesh devices implanted to treat pelvic organ prolapse and stress urinary incontinence. Although many have had no problems, a substantial minority have developed serious, long-term complications such as chronic pain, infection, vaginal bleeding and bowel problems. Mesh removal can often relieve their symptoms, but it is not always possible to remove all the mesh. Fong hopes robot-assisted surgery will provide a way of dealing with these technically challenging cases.
“Mesh removal is highly specialised and difficult surgery, and not all surgeries are successful,” she says. “I’m looking for more of a guarantee, which is what I hope the robot will give us in quite a few situations.”
The da Vinci robot consists of several robotic arms that are controlled by a surgeon sitting at a console. It offers two main advantages over conventional mesh-removal surgery: better visibility and easier access.
The robot’s greatly magnified vision allows surgeons to detect mesh that can’t be seen by the naked eye, and they can also spot – and avoid cutting – nerves and small blood vessels. In addition, the robot’s superior range of movement and tiny instruments make it easier to reach the affected areas then do the painstaking work of peeling away the mesh. “There’s only so far the human neck can turn,” says Fong.
The US$2.5 million da Vinci robots are used in hospitals around the world, particularly for urological and gynaecological surgery. In New Zealand, they are used only in private hospitals run by Southern Cross, including North Harbour Hospital where Fong – who also works for the Waitematā District Health Board – is doing the New Zealand part of the pilot study.
She says a few overseas surgeons have used robots for mesh-removal surgery, but it’s the first time it’s been done here. The pilot study is also testing what’s thought to be a world-first – robot-assisted removal of mesh through the vagina rather than through the abdomen.
“The mesh is put in through the vagina, so the best way to get it out is through the vagina, but without a robot, you really struggle to see what you’re doing.”
To prepare for the surgery, Fong spent time last year at a Sydney laboratory where she implanted several kinds of mesh devices into cadavers, then practised removing them using the robot – including transvaginally.
In April, she used transvaginal, robot-assisted surgery on a woman for the first time. Working with experienced Auckland robotic surgeon Simon van Rij, she used the technique to successfully remove a mesh device from Paula Miles of Golden Bay.
The device had originally been inserted in 2013 to treat a prolapsed bladder, causing a range of increasingly serious complications. Miles was in constant pain, had numbness in one leg and pins and needles in both feet and was so lacking in energy that she had to give up full-time work. “I’d come home from a five-hour day and have to sleep.”
Eventually, her doctors referred her to the Waitematā District Health Board to be assessed by Fong, who concluded the device had been incorrectly inserted and was pulling tight across her body. However, it was so deep in her pelvis, it would have been almost impossible to remove using conventional surgery.
At about the same time, Miles had her surgical-mesh injury claim accepted by the Accident Compensation Corporation, allowing her to be treated in a private hospital, and making it possible for her to join the pilot study.
For Miles, the results have been life-changing. “The instant I was up and about, the difference was huge. My insides felt more relaxed and I can feel that the mesh is gone. I just feel so much better.”
This article was first published in the July 13, 2019 issue of the New Zealand Listener.