Authors: Howard B Goldman Peter L Dwyer
Publish Date: 2015/11/19
Volume: 27, Issue: 3, Pages: 345-346
Abstract
If polypropylene mesh slings were found to lead to malignancy even in a small number of cases it would lead to clear practice changes The current report describes a case of clear cell carcinoma diagnosed in a patient who was also noted to have an exposed midurethral sling Clear cell carcinoma is a rare tumor that can occur primarily within the urethra or the vagina In the vagina it is often associated with in utero diethylstilbestrol DES exposure while in the urethra the majority of such cancers are associated with a urethral diverticulum The report by Lin et al 1 describes a patient who presented with urinary retention and symptoms of a urinary tract infection UTI who was found upon examination to have mesh exposure in the vaginal fornix and an inflamed and tender anterior vaginal wall She received a transvaginal tape obturator TVTo Gynecare Johnson Johnson Somerville NJ USA 10 years earlier The exposed mesh was excised but within 2 months the vaginal wall was friable ultimately invasive clear cell carcinoma was diagnosedA second patient presented to one of the authors PLD with recurrent UTIs dysuria and a 3cm paraurethral mass 14 months after placement of an Advantage midurethral sling Boston Scientific and native tissue repair had been performed She was diagnosed with squamous cell carcinoma possibly of lower urinary tract or vaginal origin Despite undergoing radical surgery she died of the diseaseWith almost 20 years of commercial availability this is the first published case report of direct proximity of a malignancy to a midurethral polypropylene sling One would expect that if this were a genuine problem we would be seeing more of such cancer cases given the millions of women with these products inserted Of course one might respond that this is the tip of the iceberg and more will appear time will tell but it seems unlikelyPresenting symptoms of the patient reported here—urinary retention—is not consistent with exposed mesh but is more consistent with a rapidly enlarging pelvic tumor She may have had exposed mesh for years and it was only discovered because of her urinary symptomsIn all likelihood this patient had asymptomatic mesh exposure and developed clear cell carcinoma Given the length and breadth of experience with polypropylene midurethral slings it is likely an incidental finding However the possibility of an association has been raised and vigilance is thus required To take this further more than case reports of associations between cancer and the use of polypropylene mesh is needed A significantly increased risk of cancer in women who have these implants must be demonstrated compared with the general population in a large cohort of women On current evidence we believe we should continue to reassure our patients of the low risk of carcinogenicity with polypropylene grafts
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