Long-term follow-up of sacrocolpopexy mesh implants at two time intervals at least 1 year apart using 4D transperineal ultrasound

Posterior mesh fixation versus non-fixation in sacrocolpopexy: A randomized clinical trial

INTRODUCTION

Urogenital prolapse affects up to 50% of women, and its treatment is essential for improving quality of life. Laparoscopic sacrocolpopexy is considered the gold standard, but there is no consensus on the optimal surgical approach. This study tests the hypothesis that the absence of posterior mesh fixation is non-inferior to its fixation.

MATERIALS AND METHODS

We conducted a randomized, single-blinded, monocentric, non-inferiority trial in Italy (NCT04358978). In Group A, the posterior mesh was placed without fixation, while in Group B, it was fixed to the rectovaginal fascia and levator ani muscle. The primary outcome was the correction of prolapse, with secondary outcomes including intraoperative parameters, postoperative characteristics, and urogenital prolapse correction at 1, 6 and 12, months, as well as long-term morbidity.

RESULTS

120 women were randomized into two groups with no significant differences. At 12 months, both groups reported no bulge symptoms, and pelvic pain was 3,3 %. Urinary dysfunction decreased in both groups, with a reduction in de novo incontinence (Group A: 1.6 %, Group B: 3.3 %) and persistent incontinence (Group A: 0 %, Group B: 7 %). Persistent constipation at 12 months was 3.3 % in Group A and 13 % in Group B. No cases of obstructed defecation or mesh erosion were observed. Five cases of failure (8.3 %) were reported in both groups, defined as Ba point reaching the hymen.

CONCLUSIONS

The absence of posterior mesh fixation is non-inferior to fixation in laparoscopic sacrocolpopexy in terms of treatment success and postoperative complications.

Safety and efficacy of spider anchoring device for apical repair in laparoscopic sacrocolpopexy: Retrospective cohort study

OBJECTIVE

The aim of the study was to assess safety and efficacy of apical support when using the soft-tissue metal fasteners of EndoFast Reliant™ SCP during laparoscopic sacrocolpopexy (LSCP).

STUDY DESIGN

This is a single-center, retrospective cohort study including all patients which underwent LSCP between 2015 and 2017. Safety outcome included the procedure and the device related complications. Effectiveness outcomes included the anatomical success of apical repair and the functional results as were obtained from the clinic and from a Quality of life questionnaire (PFDI-20).

RESULTS

Eighty-four patients, 54% with grade III and IV prolapse were included in the study. Uterus was preserved in 68% of patients with uterus. Mean follow-up period for the clinic visit was 4.5 ± 4 months. Short term anatomical success was achieved for 98.8% of the patients. Marked improvement was observed in the related symptoms including urinary incontinence. Three intra-operative complications occurred: 1 case of bladder injury, 1 case of intra-abdominal bleeding, and 1 case of post-operative vaginal bleeding. Later complications included only two patients (2.3%) complained of chronic abdominal pain. There were no cases of mesh erosion or de-novo dyspareunia. The mean follow-up period for the PFDI-20 questionnaire was 15.6 months. 75% of patients had no bulge symptoms at all. Quarter of the patients had some bulge symptoms, bothers them between somewhat to moderately according to the questionnaire grading.

CONCLUSIONS

The use of Endofast SCP fasteners for laparoscopic promonto-fixation is a safe and effective surgery. Longer follow-up and larger studies should be performed to establish the results.

Ultrasound visualization of sacrocolpopexy polyvinylidene fluoride meshes containing paramagnetic Fe particles compared with polypropylene mesh

INTRODUCTION AND HYPOTHESIS

Paramagnetic Fe particles can be added during synthetic mesh production to allow visibility on magnetic resonance imaging. Our aim was to evaluate whether transperineal ultrasound (TPUS) allows visualization, measurement, and characterization of polyvinylidene fluoride (PVDF mesh) containing Fe particles compared with regular polypropylene (PP) meshes used for sacrocolpopexy.

METHODS

Women up to 1.5 years after laparoscopic sacrocolpopexy who were implanted with a PP or PVDF mesh underwent clinical examination and 2D, 3D, and 4D TPUS. Acquired volumes were analyzed offline for mesh position at rest and maximal Valsalva and for mesh dimensions and characteristics, with the operator blinded to group assignment. The two groups were compared.

RESULTS

There were 17 women in the PP and 25 in the PVDF mesh group, without differences in baseline demographics. None had significant prolapse, recurrence, symptoms, or complications. On TPUS, mesh was visible in all patients both caudally (perineal) and cranially but was more echogenic in the PVDF mesh group. Mesh length from distal to proximal that was visible on TPUS was longer for PVDF mesh, for both anterior and posterior vaginal arms (all P < 0.05), and for mesh above the vaginal apex (P = 0.002). The inferior aspects of the mesh showed areas of double mesh layers, suggesting folding in 80% of women in both groups, without symptoms.

CONCLUSIONS

PVDF mesh permits clearer visualization and is seen over a longer stretch on TPUS, with longer visible mesh arms. The latter can be due to differences in operative technique, presence of microparticles, implant textile structure, or patient characteristics.

Short term post-operative morphing of sacrocolpopexy mesh measured by magnetic resonance imaging

BACKGROUND

Sacrocolpopexy (SC) involves suspension of the vaginal vault or cervix to the sacrum using a mesh. Following insertion, the meshes have been observed to have undergone dimensional changes.

OBJECTIVE

To quantify dimensional changes of meshes following implantation and characterize their morphology in-vivo.

DESIGN SETTING AND PARTICIPANTS

24 patients underwent SC using PolyVinyliDeneFluoride mesh loaded with Fe₃O₄ particles. Tailored anterior and posterior mesh flaps were sutured to the respective vaginal walls, uniting at the apex. The posterior flap continued to the sacrum and was attached there. Meshes were visualized on magnetic resonance (MR) imaging at 12 [3-12] (median [range]) months postoperatively and 3D models of the mesh were generated. Dynamic MR sequences were acquired during valsalva to record mesh mobility.

OUTCOME MEASURES

The area of the vagina effectively supported by the mesh (Effective Support Area (ESA)) was calculated. The 3D models' wall thickness map was analyzed to identify the locations of mesh folding. Intraclass correlation (ICC) was calculated to test the reliability of the methods. To measure the laxity and flatness of the mesh, the curvature and the ellipticity of the sacral flap were calculated.

RESULTS

The ESA calculation methodology had ICC = 0.97. A reduction of 75.49 [61.55-78.67] % (median [IQR]) in area, 47.64 [38.07-59.81] % in anterior flap, and of 23.95 [10.96-27.21] % in the posterior flap was measured. The mesh appeared thicker near its attachment at the sacral promontory (n = 19) and near the vaginal apex (n = 22). The laxity of the mesh was 1.13 [1.10-1.16] and 60.55 [49.76-76.25] % of the sacral flap was flat. We could not reliably measure mesh mobility (ICC = 0.16).

CONCLUSION

A methodology for complete 3D characterization of SC meshes using MR images was presented. After implantation, the supported area is much lower than what is prepared prior to implantation. We propose this happened during the surgery itself.