HOLLYWOOD, FLA. — Women who smoke cigarettes are at more than four times greater risk for type 1 mesh erosion following abdominal sacrocolpopexy or sacrocolpoperineopexy, compared with those who do not smoke, according to data from a case-control study.
“Mesh erosion, although uncommon, can be quite distressing for patient and physician alike,” Dr. Joye Lowman said in an interview.
“We noticed that many patients in our population who developed mesh erosion were smokers.”
Detrimental effects of smoking on wound healing have previously been demonstrated by significant data in orthopedics, dentistry, and plastic and reconstructive surgery.
“We hypothesized that if smoking has been shown to impair healing after mastectomy, face-lifts, abdominoplasty, and spinal surgery, perhaps it impairs the healing of vaginal wounds as well,” said Dr. Lowman, who is a third-year fellow in female pelvic medicine and reconstructive surgery at Indiana University, Indianapolis.
No risk factors have been shown conclusively to increase mesh erosion risk because the number of cases of mesh erosion is small, with an overall incidence of 3.4% (Obstet. Gynecol. 2004;104:805–23), Dr. Lowman said.
Another challenge is that mesh erosion can occur up to 2 years after an abdominal sacralcolpopexy (ASC).
In a previous study, researchers evaluated risk factors for mesh erosion after ASC and found a higher proportion of smokers in cases of mesh erosion, but the findings were not statistically significant (Obstet. Gynecol. 1998;92:999–1004).
To assess current smoking in a larger study, researchers retrospectively compared all cases of vaginal mesh erosion between October 2003 and June 2006. These 27 women were compared with 81 controls matched for age, menopausal status, hormone therapy use, and other factors.
All of the participants were treated at Urogynecology Associates in Indianapolis. The findings were presented at the annual meeting of the American Urogynecologic Society.
A total of seven cases (26%) and six controls (7%) reported current tobacco smoking. The risk of mesh erosion was significantly greater among the smokers, compared with nonsmokers (odds ratio 4.4).
“I was surprised that we detected such a large effect. To find an effect of this magnitude with a sample size of only 108 patients and an extensive match emphasizes the strength of this association,” Dr. Lowman said.
Erosion occurred a mean of 12 months after surgery. The most common presenting symptoms were vaginal discharge and spotting, which were reported by 96% of the participants who had mesh erosion. The type 1 propylene mesh included SoftPro (Ethicon, Somerville, N.J.) and ProLite (Atrium Medical Corp., Hudson, N.H.). Dr. Lowman has no affiliation with the companies that manufacture these mesh products.
The association between smoking and mesh erosion remained significant when the six cases and four controls who had laparoscopic surgery were excluded (OR 8.0).
So what is the physiologic link between smoking and mesh erosion? Collagen synthesis is the most significant effect. Collagen is essential to optimal tensile strength of a healing wound. Nicotine's antiestrogen effect is probably another significant effect. Vaginal atrophy and slower healing of vaginal wounds might ensue with lower estrogen levels.
Nicotine increases platelet aggregation; decreases microvascular prostacyclin levels, and inhibits fibroblast, macrophage, and red blood cell function. In addition, nicotine and carbon monoxide in cigarettes can increase cardiac workload and decrease tissue oxygen tension.
Physicians should counsel patients before an ASC or ASCP surgery of an increased risk of mesh erosion if they smoke, Dr. Lowman said.
“The effort must be made to reiterate the effects of smoking at every visit. We all know that smoking affects the heart and lungs. Broaden the discussion to include its affects on wound healing, skin—premature wrinkles, and bone—increased osteoporosis. Tell your female patients that smoking causes premature aging—that will get them motivated!”
Only 19% of participants with mesh erosion had successful medical management of their condition, defined as office excision or hormone therapy. The remaining patients were taken back to the operating room to excise the mesh vaginally.
The sample size may have been too small to detect any effect of smoking on time to diagnosis of erosion or the success rate of medical management, a possible limitation of the study.
Other factors that might reduce the risk of mesh erosion, including use of hormone therapy and perioperative antibiotics, are areas for future research, Dr. Lowman said.
“We noticed that many patients in our population who developed mesh erosion were smokers.” Lolita Jones/Elsevier Global Medical News