To compare the efficiency of the partial mesh removal(PMR) versus subtotal mesh removal(SMR), on urogenital distress, and sexual functions, in patients experienced vaginal mesh extrusion.

Between June 2014 and January 2018, fourty-five patients who experienced vaginal mesh extrusion following MUS surgeries and therefore underwent mesh excision were evaluated retrospectively. The study protocol was approved by the Local Ethics Committee. PMR was performed by the single surgeon on 19 patients, and SMR by the other single surgeon on 26 patients. 
Age and body mass index (BMI) of patients, pregnancy, vaginal delivery, menopause status, whether diabetes mellitus (DM) is present, smoking status, genitourinary system symptoms, post-void residual urine volume (PVR), previous MUS history, and mesh removal time from implantation, were recorded. Vaginal mesh extrusion was diagnosed with the physical examination. Patients underwent synthetic graft for pelvic organ prolapse, had pelvic radiation history, suspected of urethra and bladder injury in cystoscopy, were not sexually active, underwent mesh removal previously, and underwent concomitant incontinence surgery following mesh removal, were excluded from the study.
The effectiveness of surgical procedures were compared with the ‘’Urinary Distress Inventory-6 (UDI-6)’’ and the‘‘Female Sexual Function Index (FSFI)’’ forms. Patients filled out UDI-6, and IFSI forms, preoperatively and at the postoperative 6th month. “SPSS 11 for Windows” statistical package was used in statistical analyses, and the data were expressed as an arithmetic mean and standard deviation. The Chi-Square Test was performed for the calculation of categorical variables, and the Mann Whitney U Test was used to compare the mean values. A 95% confidence interval (p<0.05) was considered statistically significant.

Fourteen PMR-patients and 21 SMR-patients who met the study criteria were evaluated for the study. No difference was detected in terms of age, BMI, pregnancy, vaginal delivery, menopause status, DM, smoking status, genitourinary system symptoms, PVR, previous midurethral surgery, and mesh removal time from implantation, between two groups (p=0.583, p=0.561, p=0.359, p=0.606, p=0.594, p=0.530, p=0.533, p=0.218, p=0.630, p=0.647, p=0.359, respectively). In PMR-patients, the length of the removed mesh (2.71±0.62 cm vs 7.33±0.85 cm, p=0.001), and the duration of operation (57.28±4.77 minute vs 69.52±6.4, p=0.001) were shorter. No patients had per-operative or post-operative complications (Table 1).
At the post-operative 6th month, there was a significant improvement in UDI-6 scores and FSFI scores in both PMR, and SMR groups (p=0.001, p=0.001, p=0.001, p=0.001, respectively).  When the two groups were compared in terms of improvement rates, there was no significant difference in UDI-6 scores [(-) 30.21 ± 6.56%, vs (-) 26.33 ± 9.01%, p=0.222 ]. However, there was a statistically significant improvement in the FSFI scores in the SMR group [(+) 83.71 ± 14.81%, vs (+) 124.42 ± 36.82%, p=001]. Following mesh excision, there was no significant difference in overactive bladder (OAB) symptoms between 2 groups, with a decrease of 75% in the PMR group and 71.42% in the SMR group (p=0.721). Recurrent SUI was observed in 2 (14.2%) patients in the PMR group, and 4 (19.1%) in the SMR group at the post-operative 6th month, but no significant difference was found between two groups (p=0.544) (Table 2).

In order to make an objective evaluation in patients who underwent mesh excision, our study is important as it is the first study to investigate urogenital distress and sexual functions together. Although the limited number of the patients is a limitation of our study, the evaluation of preoperative and postoperative complaints according to objective questionnaire forms is a remarkable aspect of the current study. UDI-6 and FSFI questionnaires were completed to the patients in both groups at the diagnosis, and 6 months after mesh excision, and the rates of improvement in patients’ complaints were objectively evaluated. Statistically significant improvements were observed in both urinary and sexual functions of the patients in the post-operative period. When two groups were compared, there was no significant difference in the improvement rates in UDI-6 scores [PMR; (-) 30.21±6.56% vs SMR; (-) 26.33±9.01%, p=0.222]. However, there is a significant difference between FSFI scores of two groups, favoring the SMR group [PMR; (+) 83.71 ± 14.81% vs SMR; (+) 124.42 ± 36.82%, p=0.001].

In conclusion, vaginal mesh extrusion is an important complication that may occur following mesh-related procedures. The patient group which has risk factors for mesh extrusion in the pre-operative period may be determined, and patients should be informed about mesh complications. In addition, in cases where the extruded portion should be removed, patients should be informed that the de novo SUI may develop after excision surgery and that it may require a new surgical procedure.
	In cases where extrusion is developed, partial or subtotal/total removal of mesh provides a significant improvement in patients’ complaints of sexual dysfunction related to extrusion. The rates of improvement in sexual functions is much more pronounced in cases undergone SMR.