Transvaginal synthetic mesh has been used to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women since the 1950’s. In England about 100,000 women had transvaginal mesh for stress incontinence and 27,000 for prolapse from 2008/9 until 2016/2017 (3).
In recent years it has come to light that about 10% of women have suffered complications related to the mesh (2). These complications include but are not limited to pain, sexual dysfunction, mesh erosion, problems with mobility and psychological trauma.
In 2011, The International Continence Society (ICS) and the International Urogynaecological Association (IUGA) published the CTS tool to classify mesh-related complications. It was created with the aim of standardising language used and developing a registry to log complications (1)
The CTS describes a complication relating to its anatomical site and severity. ‘C’ stands for the type of complication e.g. pain or erosion and then branches into site and severity. ‘T’ is the time to when the complication is clinically diagnosed. ‘S’ relates to the  anatomical site of the complication.  

The aim of this study was to assess the usability of the CTS system by retrospectively analysing the mesh complications referred to our centre. We hypothesized that not all mesh-related complications our patients have experienced are represented on the CTS.

A retrospective chart review was performed of all adult women (over the age of 18) who underwent any mesh removal surgery for mesh complications between October 2011 and March 2023 at our tertiary-care referral centre. Data was extracted from the electronic patient records including operation notes and clinic letters related to the surgery.

There were 206 operations performed for mesh complications between October 2011 and March 2023. Table 1 shows the types of mesh removed, the type of operation and the complications.

20% (52/264) of complications have been difficult to classify either because the patient had more than one type of mesh or had lower urinary tract dysfunction such as recurrent stress urinary incontinence, detrusor overactivity and urinary retention.
There were 59 patients who had more than one complication which would need multiple data entry into the CTS classification system.

Reading the clinic letters also revealed that many patients presented with sexual dysfunction or psychological problems, these are not classifiable using the CTS system but were significant for the patients to the point that they wanted the mesh to be removed.

The CTS system allows only one mesh complication to be chosen per entry and if patients have more than one complication then multiple entries have to be entered. The system also does not specify the type of mesh used and does not include functional complications. Using the CTS system risks missing significant data, particularly in terms of patient’s symptoms. 
The CTS system also has discrepancy in terms of reporting timings between the paper version and the online version and the time frames are not reflective of clinical practice as patients tend to present after 5 years based on our data (not presented here).
With regards to site, only one can be chosen and if a mesh has extruded into more than one organ then that would be missed.

The CTS system is outdated, not user friendly, and leads to loss of significant data capture. It is therefore not fit for purpose and needs updating with a new more reliable tool developed to include a wider range of complications including lower urinary tract dysfunction, psychological problems, sexual dysfunction, and auto immune disorders. It should also include the type of mesh, the ability to choose more than one complication with a wider range of time-frames. This will allow better capture of mesh related complications.

Haylen. BT, Freeman. RM, Swift. SE, Cosson. M, Davila. GW, Deprest. J, Dwyer. PL, Fatton. B, Kocjancic. E, Lee. J, Maher. C, Rizk. DE, Petri. E, Sand. PK, Schaer. GN, Webb. P. (2010) ICS / IUGA Joint Terminology and Classification Report of the complications related directly to the insertion of prostheses (meshes, implants, tapes) & grafts in female pelvic floor surgery. ICS Documents
Keltie. K, Elneil. S, Monga. A, Patrick. H, Powell. J, Campbell. B, Sims. AJ (2017) Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92’246 women. Scientific Reports. 7 (1205)
NHS Digital (2018) NHS Digital Publishes statistics on vaginal mesh procedures. NHS Digital publishes statistics on vaginal mesh procedures - NDRS

Continence 7S1 (2023) 100770
DOI: 10.1016/j.cont.2023.100770