In vivo comparison of suburethral sling materials

Mersilene tape versus conventional sutures in transvaginal cervical cerclage: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the effectiveness of Mersilene tape versus alternative suture types in prolonging singleton pregnancies as well as other pregnancy and neonatal outcomes, in cases of history-, ultrasound-, and exam-indicated cervical cerclage.

METHODS

A systematic review was conducted to identify relevant studies comparing different suture types in cervical cerclage procedures. The primary outcome of interest was preterm birth (PTB) rate < 37, <35, < 28, and < 24 weeks. Statistical analyses were performed to determine the relationship between suture type and various outcomes.

RESULTS

A total of five studies, including three randomized controlled trials (RCTs) and two retrospective studies, with a combined participation of 2325 individuals, were included. The pooled analysis indicated no significant association between suture type and PTB at less than 37 weeks of gestation (RR: 1.02, 95% CI: 0.65-1.60, p < 0.01, I2 = 74%). Women who received Mersilene tape had a higher risk of PTB at 34-37 weeks (RR: 2.62, 95% CI: 1.57-4.37, p = 0.69, I2 = 0%), but a lower risk of PTB at less than 34 weeks (RR: 0.43, 95% CI: 0.28-0.66, p = 0.66, I2 = 46%). No statistically significant differences were observed for PTB before 28 weeks (RR: 1, 95% CI: 0.65-1.53, p = 0.70, I2 = 0%), before 24 weeks (RR: 0.86, 95% CI: 0.60-1.23, p = 0.33, I2 = 0%), incidence of chorioamnionitis (RR: 0.97, 95% CI: 020-4.83, p < 0.01, I2 = 95%), neonatal intensive care unit (NICU) admission (RR: 0.79, 95% CI: 0.28-2.22, p = 0.08, I2 = 67%) and neonatal death (RR: 1.00, 95% CI: 0.42-2.35, p = 0.17, I2 = 48%).

CONCLUSION

Our findings suggest that Mersilene tape does not reduce the risk of PTB before 37, 28 or 24 weeks. We observed higher risk of preterm birth between 34 and 37 weeks with Mersilene tape but lower incidence before 34 weeks, a period with higher neonatal morbidity and mortality. Due to the limited number of studies, our results and their clinical significance should be interpreted with caution.

Joint Report on Terminology for Surgical Procedures to Treat Stress Urinary Incontinence in Women

INTRODUCTION AND HYPOTHESIS

Standardized terminology for surgical procedures commonly performed to treat stress urinary incontinence in women is needed to facilitate research, clinical care, and teaching in female pelvic medicine and reconstructive surgery.

METHODS

This report combines the input of members of the American Urogynecologic Society and the International Urogynecological Association, assisted by external referees. Extensive searches of the literature were performed, including Instructions for Use brochures and original source documents where possible. Historical context was considered along with procedural modifications, and expert opinion was included when appropriate.

RESULTS

A terminology report for the procedures commonly performed to treat stress urinary incontinence in women was produced. Included procedures are midurethral sling, retropubic colposuspension, pubovaginal sling, urethral bulking, and artificial urinary sphincter. Appropriate figures have been included to supplement and help clarify the text. Ongoing review will be performed periodically to keep the document updated and widely acceptable.

CONCLUSIONS

This document is a literature and consensus-based terminology report for surgical procedures to treat stress urinary incontinence in women. Future publications in female pelvic medicine and reconstructive surgery should use this standardized terminology whenever possible.

Efficacy of different cerclage suture materials in reducing preterm birth

Objective: To compare the efficacy of monofilament suture, braided polyester thread, and 5 mm tape suture in reducing preterm birth (PTB).Study design: Women who received a cerclage at Touro Infirmary, New Orleans, LA, USA, between 1 January, 2011 and 31 December, 2016 were identified using ICD-9/10 codes. All charts were reviewed for demographic and obstetrical variables including gestational age (GA) at delivery.Results: Of 145 women who received a cerclage, 36 were excluded due to incomplete charts leaving 109 for analysis. There was no significant difference in gestational age at cerclage placement or delivery among women with monofilament, braided, or 5 mm tape cerclages (p = .936 and p = .919, respectively) nor was there a difference in the proportion who delivered at ≥32, 34, or 37 weeks across groups with differing cerclage material (p = .270, p = .275, and p = .419, respectively). There was no difference in GA at delivery for patients who received 17-OHP compared to those who did not (p = .362). There were also no differences with respect to birth outcomes such as birthweight (p = .938), Apgar scores (p = .477, p = .430) or neonatal intensive care admission rates (NICU) (p = .304). Analysis revealed no difference in characteristics between groups including history of PTB or indication for removal (p = .371, p = .317).Conclusion: We found no difference in pregnancy prolongation when comparing different suture material used for indicated cerclages. We also found no differences with respect to rates of maternal infection or adverse neonatal outcomes among groups.RationaleThis study was conducted to evaluate the efficacy of different suture materials in increasing gestational age at delivery and reducing preterm birth.

No incision and tension-free vaginal sling for stress urinary incontinence: The role of knotless barbed suture

Midurethral mesh sling is the most performed incontinence procedure. This hypotheses propose knotless barbed suture could be positioned as a tension-free trans-vaginal sling under the mid-urethra without vaginal incision. Knotless suture sling support and stabilize mid-urethra when intraabdominal pressure increase. This procedure is designed to replace midurethral mesh sling operation, aiming at reducing complications. It is completed in a similar way with retropubic mesh sling procedure, and less invasive. This involve the passage of fine needle from suprapubic skin to midurethral vaginal wall, and knotless suture passing through in fine needle as a U shape. The foundational promises for this hypothesis pertain to two clinical facts: midurethral sling procedure is a gold standard treatment, and the knotless suture offer superior tissue holding or fixation strength originated from the unique barbed design.

Scaffolds for Pelvic Floor Prolapse: Logical Pathways

Pelvic organ prolapse (POP) has borrowed principles of treatment from hernia repair and in the last two decades we saw reinforcement materials to treat POP with good outcomes in terms of anatomy but with alarming complication rates. Polypropylene meshes to specifically treat POP have been withdrawn from market by manufactures and a blank space was left to be filled with new materials. Macroporous monofilament meshes are ideal candidates and electrospinning emerged as a reliable method capable of delivering production reproducibility and customization. In this review, we point out some pathways that seem logical to be followed but have been only researched in last couple of years.

Preterm Birth Prevention Post-Conization: A Model of Cervical Length Screening with Targeted Cerclage

Women with a history of excisional treatment (conization) for cervical intra-epithelial neoplasia (CIN) are at increased risk of preterm birth, perinatal morbidity and mortality in subsequent pregnancy. We aimed to develop a screening model to effectively differentiate pregnancies post-conization into low- and high-risk for preterm birth, and to evaluate the impact of suture material on the efficacy of ultrasound indicated cervical cerclage. We analysed longitudinal cervical length (CL) data from 725 pregnant women post-conization attending preterm surveillance clinics at three London university Hospitals over a ten year period (2004-2014). Rates of preterm birth <37 weeks after targeted cerclage for CL<25mm were compared with local and national background rates and expected rates for this cohort. Rates for cerclage using monofilament or braided suture material were also compared. Of 725 women post-conization 13.5% (98/725) received an ultrasound indicated cerclage and 9.7% (70/725) delivered prematurely, <37weeks; 24.5% (24/98) of these despite insertion of cerclage. The preterm birth rate was lower for those that had monofilament (9/60, 15%) versus braided (15/38, 40%) cerclage (RR 0.7, 95% CI 0.54 to 0.94, P = 0.008). Accuracy parameters of interval reduction in CL between longitudinal second trimester screenings were calculated to identify women at low risk of preterm birth, who could safely discontinue surveillance. A reduction of CL <10% between screening timepoints predicts term birth, >37weeks. Our triage model enables timely discharge of low risk women, eliminating 36% of unnecessary follow-up CL scans. We demonstrate that preterm birth in women post-conization may be reduced by targeted cervical cerclage. Cerclage efficacy is however suture material-dependant: monofilament is preferable to braided suture. The introduction of triage prediction models has the potential to reduce the number of unnecessary CL scan for women at low risk of preterm birth.

Experimental use of a cellulosic biopolymer as a new material for suburethral sling in the treatment of stress urinary incontinence

PURPOSE

To analyze the interaction between the cellulose exopolysaccharide (CEC) and urethral tissue when used as a pubovaginal sling.

MATERIALS AND METHODS

Forty Wistar rats were divided into four groups. In groups A and B the cellulose exopolysaccharide (CEC) was implanted around the urethral tissue (bladder neck below the upper margin) and the rats were sacrificed at 30 and 90 days. Similar procedure was used in groups C and D using a polypropylene mesh. After sacrifice bladder and urethra were sent for histological analysis. The histological parameters (inflammatory reaction) by evaluated by quantitative analysis. For collagen deposition analysis it was used stereological method.

RESULTS

The cellulose exopolysaccharide (CEC) was inert and well preserved at the implanted region at the time of examination. Morphologic alterations were not found at the CEC implant but some reactions of foreign body type were observed at the adjacent structures. In some areas a process of neovascular formation was observed. Stereological analysis at the suburethral area showed a significant difference in collagen presence in favor of CEC.

CONCLUSIONS

The CEC implant showed adequate results when used as a suburethral sling with good integration to the host tissue, preserving its architecture.

Treatment of stress urinary incontinence with a generic transobturator tape

OBJECTIVE

To evaluate the efficacy and safety of using a generic tape tailored from type 1 monofilamentous, macroporous polypropylene mesh during transobturator tape (TOT) surgery.

METHODS

A prospective study was performed in a tertiary center in Cairo, Egypt, between July 2004 and December 2013. Women with stress urinary incontinence scheduled for TOT surgery using the outside-in technique were recruited. Monarc tape was used in all patients until November 2005, after which it was used for patients who could afford it only; generic tape was used in the other patients. The primary outcome measures were the objective and subjective cure rates.

RESULTS

Overall, 431 women were included in analyses. After 5 years of follow-up, objective cure was achieved in 143 (94.1%) of 152 women who received Monarc tape and 249 (89.2%) of 279 who received the generic tape (P=0.135). Subjective cure was achieved in 121 (79.6%) women who received the Monarc tape and 236 (84.6%) women who received the generic tape (P=0.229). There were no significant between-group differences in postoperative urgency, de novo urgency, urge incontinence, voiding dysfunction, urinary retention, vaginal erosion, or the frequency of TOT-related reoperation or repeat anti-incontinence procedures.

CONCLUSION

The TOT outside-in procedure can be easily, safely, and effectively performed in low-resource settings using a generic polypropylene tape.

Biomaterials for pelvic floor reconstructive surgery: how can we do better?

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are major health issues that detrimentally impact the quality of life of millions of women worldwide. Surgical repair is an effective and durable treatment for both conditions. Over the past two decades there has been a trend to enforce or reinforce repairs with synthetic and biological materials. The determinants of surgical outcome are many, encompassing the physical and mechanical properties of the material used, and individual immune responses, as well surgical and constitutional factors. Of the current biomaterials in use none represents an ideal. Biomaterials that induce limited inflammatory response followed by constructive remodelling appear to have more long term success than biomaterials that induce chronic inflammation, fibrosis and encapsulation. In this review we draw upon published animal and human studies to characterize the changes biomaterials undergo after implantation and the typical host responses, placing these in the context of clinical outcomes.

Cerclage outcome by the type of suture material (COTS): study protocol for a pilot and feasibility randomised controlled trial

BACKGROUND

Cervical incompetence is one of the causes of preterm birth and mid-trimester pregnancy loss. Cervical cerclage is a surgical procedure to treat cervical incompetence. Cervical cerclage reduces the incidence of preterm birth in women at risk of recurrent preterm birth, without a statistically significant reduction in perinatal mortality or neonatal morbidity. Multifilament/braided sutures such as Mersilene tape have been traditionally used for cervical cerclage. Braided sutures, particularly mesh-like non-absorbable sutures, have been associated with an increased risk of infection and, hence, some obstetricians prefer to use monofilament/non-braided sutures. However, these claims are not substantiated by any scientific or clinical evidence.We propose a pilot/feasibility study which will provide the necessary information for planning a definitive trial investigating the clinical effectiveness of monofilament non-braided suture materials in reducing pregnancy loss rate following cervical cerclage compared to the traditional multifilament braided sutures.

METHODS/DESIGN

Women eligible for elective or ultrasound-indicated cerclage at 12 to 21 + 6 weeks of gestation will be randomised to having the procedure using either a monofilament non-braided suture (Ethilon) or a Multifilament braided suture (Mersilene tape) inserted using a McDonald technique. Consent for participation in the Cerclage outcome by the type of suture (COTS) study will be obtained from each eligible participant.

CLINICAL TRIALS REGISTRATION

COTS is registered with the International Standard Research for Clinical Trials (ISRCTN17866773). Registered on 27 March 2013.

Visualization of polypropylene and polyvinylidene fluoride slings in perineal ultrasound and correlation with clinical outcome

INTRODUCTION AND HYPOTHESIS

Complications and malfunctioning after TOT can occur due to several factors, such as the material of the sling. The aim of the present study is to evaluate morphology and functionality of two types of slings (PVDF; polypropylene) in vivo using perineal ultrasound (PUS).

MATERIALS

In n = 47 women with TOT four criteria for PUS were taken and checked for possible differences: vertical stability of the sling position during Valsalva manoeuvre and contraction; distance "sling to urethra"; width of the sling and condition of the selvedges.

RESULTS

We observed an increased vertical displacement of the PP-slings, a significantly smaller variance to the extent of the displacement in PVDF-slings (P < 0.01), a significantly larger distance between sling and urethra (P < 0.001) in PVDF-slings, and a significantly smaller width of the PP-slings (P < 0.0001).

CONCLUSION

Significant differences were found between the slings according to the four criteria. There was no difference established between the slings in the improvement of continence and no significant influence of the parameters was found for the resulting state of continence. In future studies, PUS may help to link differences in the morphology and functionality of in vivo slings to their material properties.

Demands and properties of alloplastic implants for the treatment of stress urinary incontinence

Surgical treatment of stress urinary incontinence changed dramatically with the introduction of the tension-free vaginal tape. Owing to its high efficacy and minimal patient discomfort this new minimally invasive procedure quickly obtained widespread acceptance and superseded the abdominal colposuspension as the gold standard. In the course of success of the original method a number of tension-free vaginal tapes flooded the market, varying in approach and material. These variations may strongly influence the safety, efficacy and long-term results of tension-free vaginal tape and its major modification, the transobturator technique. Therefore, it is the aim of this review to closely illuminate available materials and complications associated with this procedure. An extensive Medline search of the published literature up until 2006 on the subject of stress urinary incontinence was carried out. All sources identified were reviewed with particular attention to the method applied, the properties of the mesh materials and clinical complications. Apart from several technical variations, there are marked differences between the different vaginal sling materials, ranging from absorbable collagens over polypropylene to allografts. Although performed globally in substantial and increasing numbers, minimally invasive techniques for the surgical treatment of stress urinary incontinence are lacking sufficient safety data.

Posterior Intravaginal Slingplasty versus Unilateral Sacrospinous Ligament Fixation in Treatment of Vaginal Vault Prolapse

Objective. To investigate the differences in efficacy, postoperative complications, and patient satisfaction between posterior intravaginal slingplasty (PIVS) and unilateral sacrospinous ligament fixation (SSLF) procedures. Study Design. A retrospective study of thirty-three women who underwent PIVS or SSLF treatment for vaginal vault prolapse in Oulu University Hospital. The patients were invited to a follow-up visit to evaluate the objective and subjective outcomes. Median follow-up time was 16 months (range 6–52). The anatomical outcome was detected by the Pelvic Organ Prolapse Quantification (POP-Q) system. Information on urinary, bowel, and sexual dysfunctions and overall satisfaction was gathered with specific questionnaire. The data were analyzed using Mann-Whitney U test and Fisher's exact test. Results. Mesh erosion was found in 4 (25%) patients in the PIVS group. Anatomical stage II prolapse or worse (any POP-Q point ≥−1) was detected in 8 (50%) patients in the PIVS group and 9 (53%) patients in the SSLF group. Overall satisfaction rates were 62% and 76%, respectively. Conclusion. The efficacy of PIVS and SSLF is equally poor, and the rate of vaginal erosion is intolerably high with the PIVS method. Based on our study, we cannot recommend the usage of either technique in operative treatment of vaginal vault prolapse.

Pregnancy outcome after elective cervical cerclage in relation to type of suture material used

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it.

Histological evaluation of the biocompatibility of polyurea crosslinked silica aerogel implants in a rat model: a pilot study

Background

Aerogels are a versatile group of nanostructured/nanoporous materials with physical and chemical properties that can be adjusted to suit the application of interest. In terms of biomedical applications, aerogels are particularly suitable for implants such as membranes, tissue growth scaffolds, and nerve regeneration and guidance inserts. The mesoporous nature of aerogels can also be used for diffusion based release of drugs that are loaded during the drying stage of the material. From the variety of aerogels polyurea crosslinked silica aerogels have the most potential for future biomedical applications and are explored here.

Methodology

This study assessed the short and long term biocompatibility of polyurea crosslinked silica aerogel implants in a Sprague-Dawley rat model. Implants were inserted at two different locations a) subcutaneously (SC), at the dorsum and b) intramuscularly (IM), between the gluteus maximus and biceps femoris of the left hind extremity. Nearby muscle and other internal organs were evaluated histologically for inflammation, tissue damage, fibrosis and movement (travel) of implant.

Conclusion/Significance

In general polyurea crosslinked silica aerogel (PCSA) was well tolerated as a subcutaneous and an intramuscular implant in the Sprague-Dawley rat with a maximum incubation time of twenty months. In some cases a thin fibrous capsule surrounded the aerogel implant and was interpreted as a normal response to foreign material. No noticeable toxicity was found in the tissues surrounding the implants nor in distant organs. Comparison was made with control rats without any implants inserted, and animals with suture material present. No obvious or noticeable changes were sustained by the implants at either location. Careful necropsy and tissue histology showed age-related changes only. An effective sterilization technique for PCSA implants as well as staining and sectioning protocol has been established. These studies further support the notion that silica-based aerogels could be useful as biomaterials.

Gluteo-vaginal fistula: a long-term complication of posterior intravaginal slingplasty

A 67-year-old lady presented to the surgical outpatient clinic with a 4 month history of recurrent purulent discharge from her left buttock. Four years and 4 months prior to this she underwent a posterior intravaginal slingoplasty for vaginal prolapse and urinary stress incontinence. An MRI demonstrated a long gluteo-vaginal fistula tract from the posterior wall of the vaginal vault through the left ischiorectal fossa to the skin. An examination under anaesthesia revealed that the fistulous tract was surrounding the intact mesh used for the posterior intravaginal slingoplasty. The mesh was removed, the fistula tract excised and the perineal wound marsupialised. The patient was discharged 5 days later. The wound healed within 4 weeks and she remains sepsis free 2 years on.

Review article: Mid-urethral synthetic slings for female stress urinary incontinence

• Mid-urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. • There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid-urethra. • Long-term follow-up has been published for the original tension-free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow-up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. • Level 1 evidence with long-term follow-up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). • Two recent meta-analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta-analysis included 11 studies published 2008-2009, which found that the short-term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37-1.00), nearly reaching statistical significance (P= 0.05). • This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).

A randomised controlled trial comparing TVT, Pelvicol and autologous fascial slings for the treatment of stress urinary incontinence in women

OBJECTIVE

To compare TVT(TM) , Pelvicol(TM) and autologous fascial slings (AFSs).

DESIGN

A multicentre randomised control trial.

SETTING

Four units in the UK.

POPULATION

Women requiring primary surgery for stress urinary incontinence (SUI).

METHODS

A total of 201 women with urodynamically proven stress incontinence were randomised into three groups and assessed at baseline, 6 weeks, 6 months and 1 year.

MAIN OUTCOME MEASURE

The primary outcome was patient-reported improvement rates. Secondary outcomes included operative complications/time, intermittent self-catheterisation (ISC) and re-operation rates. The quality-of-life tools used were the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) and EuroQoL.

RESULTS

Fifty women had a Pelvicol(TM) sling, 79 had AFSs and 72 had TVT(TM). At 6 months the Pelvicol(TM) arm had poorer improvement rates (73%) than TVT(TM) (92%)/AFS (95%); P=0.003. At 1 year only 61% of the Pelvicol(TM) slings remained as improved, versus 93% of TVTs and 90% of AFSs (P<0.001). Pelvicol(TM) has poorer dry rates (22%) than TVT(TM) (55%)/AFS (48%) (P=0.001) at 1 year; hence, the Pelvicol(TM) arm was suspended following interim analysis. There is no difference in the success rates between TVT(TM) and AFS. One in five women in the Pelvicol(TM) arm had further surgery for SUI by 1 year, but none required further surgery in the other arms. AFS took longer to do (54 minutes versus 35 minutes for TVT(TM) /36 minutes for Pelvicol(TM) ) and had higher ISC rates (9.9 versus 0% Pelvicol(TM) /TVT(TM) 1.5%). Hospital stay was shortest for TVT(TM) (2 days). Most BFLUTS domains showed improvement in all three arms. The improvement for women in the Pelvicol(TM) arm, however, was less than for women in the other arms in several key domains.

CONCLUSIONS

Pelvicol(TM) cannot be recommended for the management of SUI. TVT(TM) does not have greater efficacy than AFS, but does utilise fewer resources.

Actinomyces infection associated with the transobturator sling

We present a case of Actinomyces infection associated with the transobturator sling. The patient had a transobturator sling complicated only by a left vaginal sulcal perforation. She subsequently developed mesh erosion that led to two partial mesh resections performed in the operating room at 6 weeks and again at 6 months after the initial surgery. She subsequently required a groin dissection and removal of the entire left side of the sling due to persistent infection. The presence of a foreign body is believed to create an environment that makes growth of the bacteria more likely. With increased use of artificial mesh in incontinence and prolapse surgery, we may see increasing numbers of these types of infections.

Isolation of fibroblasts for coating of meshes for reconstructive surgery: differences between mesh types

Aims: An extensive colonization of surgical meshes with autologous fibroblasts may reduce complications. Therefore, we aimed to establish a technique that allows isolation and propagation of fibroblasts from vaginal biopsies. Using these cells we tested the applicability of several clinically applied meshes for fibroblast coating. Materials & methods: Fibroblasts were isolated from vaginal tissue after digestion with collagenase. Characterization was performed by immunostaining for cytokeratin 5, 6 and 14, smooth muscle actin and vimentin. A semiquantitative technique was applied to determine the degree of mesh coating 5 h and 5 weeks after seeding of fibroblasts. Seven meshes of different mesh types have been tested. Results: Cells with a fibroblast-like morphology have been isolated from vaginal tissue and could be propagated for at least 12 passages, resulting in a total number of 1.2 × 107 cells. Immunostaining showed that cells were positive for the mesenchymal cell marker vimentin and negative for smooth muscle actin, as well as the epithelial cell markers cytokeratin 5, 6 and 14, supporting their classification as fibroblasts. Clear differences in fibroblast colonization between the seven tested mesh types have been observed. Polypropylene mesh Obtape® showed an acceptable covering with fibroblasts. The best coating was obtained for xenograft-based meshes, but under cell-culture conditions the mesh showed signs of decomposition. Conclusion: We have established a technique that allows isolation and propagation of vaginal fibroblasts. The result of vaginal fibroblast colonization of allograft-based meshes strongly depends on the mesh type, whereby the best coating could be achieved for a polypropylene mesh.

Closing the chapter on obtape: a case report of delayed thigh abscess and a literature review

BACKGROUND

We report a case of delayed abscess formation 33 months after Obtape transobturator tape insertion, and we review the relevant literature.

CASE

A 73-year-old woman presented with groin pain, swelling, and purulent discharge 33 months after Obtape insertion. Examination showed a vaginal erosion and right groin abscess. Oral antibiotics resulted in significant symptomatic improvement. The patient underwent complete tape removal and drainage of infection. She continues to suffer from urinary incontinence.

CONCLUSION

Abscess formation and undiagnosed mesh erosion can occur up to 33 months after Obtape insertion, longer than previous reports have described. This highlights the need for continued vigilance in patients who have undergone Obtape insertion. Vaginal mesh erosions warrant careful repair in order to avoid delayed infectious complications.

Gluteo-vaginal sinus formation complicating posterior intravaginal slingplasty followed by successful IVS removal. A case report and review of the literature

Posterior intravaginal slingplasty (IVS) is a technique used for the treatment of apical prolapse. Type III meshes have been mostly used with this technique. In this article, a case of bilateral gluteo-vaginal sinus tract formation that complicated a posterior vaginal slingplasty with a type III mesh is presented. At 3 months follow-up, the patient complained for bulking through the vagina, continuous offensive vaginal discharge, and constant pain at the buttocks. She had prolapse recurrence, and there was defective healing at the gluteal entry points of the posterior IVS. Ten months after the initial surgery, she underwent a laparotomic subtotal hysterectomy and sacrocervicopexy with prolene type I mesh. At the same time, the posterior mesh was removed allowing the surgeon to discover communication of the canal of the mesh extending from gluteal incisions to the vagina epithelium. The sinus tract was managed surgically with excision of the surrounding tissues. There was no recurrence or other complications at 2 months follow-up.

Prospective Clinical Trial Comparing Obtape® and DUPS to TVT: One-Year Safety and Efficacy Results

OBJECTIVES

Obtape and DUPS are modifications of the original TVT procedure. To test these new products in terms of safety and efficacy, we designed a prospective clinical trial with a follow-up of at least 1 yr.

METHODS

We randomized 190 consecutive females with SUI for this study. They were evaluated by history, ICIQ-SF, physical examination, cystoscopy, UDS, and the 1-h pad test. Patients were reevaluated at 1, 6, and 12 mo. The ICIQ-SF and pad test were repeated at 1-yr follow-up.

RESULTS

There were 78, 32, and 80 patients in the Obtape, DUPS, TVT arms, respectively. An interim analysis after 32 patients in each arm indicated postoperative retention rates of 3 (9.4%), 6 (18.8%), and 4 (12.5%) patients in Obtape, DUPS, and TVT groups, respectively. Because of higher retention rate and suprapubic discomfort, DUPS was discontinued. At the end of the study, complete retention rates were 6 (7.8%), 6 (18.8%), and 6 (7.5%) in Obtape, DUPS, and TVT, respectively. TVT was the only procedure with bladder perforations at a rate of 14%. However, Obtape and DUPS were associated with more postoperative complications including complete retention, urethrolysis, hematoma, mesh erosion, UTI, and wound infection (13%, 28%, and 8%; p< or =0.025). At 1 yr, 83%, 94%, and 86% of patients in the Obtape, DUPS, and TVT groups were objectively cured (p>0.05).

CONCLUSIONS

TVT was the only procedure associated with bladder perforation, but there were more postoperative complications with Obtape and DUPS. No statistically significant differences in cure rates were observed at 1-yr follow-up. Longer follow-up is needed to confirm these results.

Polypropylene Midurethral Tapes Do Not Have Similar Biologic and Biomechanical Performance in the Rat

OBJECTIVES

To evaluate the biomechanical properties and histologic changes of different commercially available polypropylene midurethral tapes (MUTs) after implantation in the rat.

METHODS

Pieces of Advantage, intravaginal slingplasty (IVS), suprapubic arch sling (SPARC), and tension-free vaginal tape (TVT) were implanted over the rectus fascia of rats, with six rats serving as controls. On retrieval 24 wk later, the degree of adherence and sample measurements were recorded. Biomechanical testing of the retrieved samples was performed using the uniaxial loading method. Histologic evaluation of the samples under light microscopy included the following parameters: inflammatory infiltrate, fibrosis, mast cell presence, muscular infiltration, and collagen filling of the mesh.

RESULTS

No mesh extrusion or infection was encountered. The biomechanical and histologic results were consistent within each group. TVT displayed peculiar adherence characteristics not found among the other brands. No statistically significant difference were found in mean peak load and extension at peak load among the four tested brands. Stiffness of TVT was significantly lower than that of each of the other three brands. Stiffness of Advantage was significantly higher than that of SPARC. The histologic findings differed from one MUT brand to another. By grading certain histologic parameters, an untested model to assign a score for biocompatibility potential in the rat, to different MUTs, was developed.

CONCLUSIONS

Commercially available polypropylene MUTs display different biologic and biomechanical properties in the rat.

The use of synthetic sub-urethral slings in the treatment of female stress urinary incontinence

We set out to review the existing literature regarding the use of synthetic suburethral sling products for the treatment of female stress urinary incontinence. Products currently implanted are examined and scrutinized, and evidence regarding their efficacy and complication rates is noted. Additionally, specifics of presently utilized synthetic materials, including construction method and biocompatibility, are explored and directly correlated to currently marketed products. This investigation was undertaken with the use of the Medline database. Studies pertaining to synthetic or surgical mesh, as well as each specific suburethral sling product, are included. Our findings and ultimately our recommendations stem from the preponderance of evidence supporting the continued use of knitted, macroporous polypropelene mesh slings. Several existing marketed products detailed in the study fit this description. Specific reference is made to recent reports of vaginal erosions and deep space infections related to several specific products. A cautionary note is also made regarding the implantation of transobturator sling products currently marketed without the necessary pre-market testing, potentially placing the public at risk. From the currently available literature on biomaterials, it seems clear that knitted macroporous polypropylene is the material of choice for suburethral implantation. With respect to the means and techniques by which these mesh materials are suburethrally implanted, the surgeon's choice often dictates which method is used, but recent experience has demonstrated that the transobturator approach can be equally as effective as the traditional tension-free vaginal tape, with less-associated morbidity. Ongoing randomized controlled trials will further clarify and distinguish between methods.

Mesh infection without erosion after ObTape sling insertion: a diagnostic challenge

Infection is a recognised complication of using synthetic mesh tapes in continence surgery. It has only been reported alongside erosion after trans-obturator sling insertion for urodynamic stress incontinence. A 41-year-old patient developed mesh infection. This infection was diagnosed 16 months after insertion, when it became an abscess and discharged through her groin. The condition was not suspected earlier, despite having examination under anesthesia and repeat cystoscopy. The patient recovered upon removing the mesh and remains continent. This case documents the possible development of mesh infection without erosion. It highlights the importance of taking this possibility into consideration when dealing with patients after continence surgery and explores how it can be detected.

Abscess formation at the ischiorectal fossa 7 months after the application of a synthetic transobturator sling for stress urinary incontinence in a type II diabetic woman

A 50-year-old diabetic woman was referred to our unit because of high fever, foul-smelling vaginal discharge and pain in the leg, 7 months after undergoing surgery for application of a transobturator suburethral sling. Patient evaluation revealed erosion of the tape through the vaginal wall; the infection had spread to the region of the internal obturator muscle and then up to the anterior recess of the ischiorectal fossa. The patient underwent surgery for sling removal, antibiotic therapy and, finally, surgical incisions to facilitate drainage of the abscess. All these passages were necessary to obtain complete resolution of the symptoms. Infectious complications are possible after transobturator sling procedures. Patients should then be informed about the risks of erosion and infection and be warned that the appearance of pain and foul-smelling vaginal discharge may indeed be the first symptom of subsequent and much more severe infectious complications.

Tensile strength and host response towards different polypropylene implant materials used for augmentation of fascial repair in a rat model

We compared inflammatory response, fibrosis and biomechanical properties of different polypropylene materials from one manufacturer (Tyco Healthcare) in a rat model for primary fascial repair. Full-thickness abdominal wall defects were primarily repaired using 'overlay' technique. Multifilament implants were Surgipro SPM and SPMW, the latter a wider-weave type of the former. Monofilament SPMM implants and polypropylene suture repair (Surgipro II) served as controls. Explants were evaluated macroscopically and changes in thickness, shrinkage and tensile strength were measured. Inflammatory and connective tissue response was assessed on haematoxylin-eosin and Movat stains. Immunohistochemistry was done to localise rat macrophages/monocytes. Multifilament materials induced a shorter acute inflammatory response and more pronounced chronic inflammatory reaction compared to monofilament implants. Macrophages could be found deep in interstices 7.5 by 12.5 microm. No difference in collagen deposition and neovascularisation was observed. At 90 days time point, explants reconstructed with tighter woven multifilament SPM were weaker than sutured or SPMM controls. Overall shrinkage of 10% was comparable for all groups.

Voiding Dysfunction Following Removal of Eroded Synthetic Mid Urethral Slings

PURPOSE

Voiding dysfunction following genitourinary erosion of synthetic mid urethral slings is not clearly reported. We investigated the incidence of voiding dysfunction in patients following sling excision due to vaginal, urethral or intravesical mesh erosion.

MATERIALS AND METHODS

Retrospective review identified 19 patients with genitourinary erosion of polypropylene mesh slings. Comprehensive urological evaluation was performed in all patients, and perioperative and postoperative data were analyzed. Voiding dysfunction was defined as refractory storage symptoms, emptying symptoms and pelvic pain. All subsequent medical and surgical interventions were recorded.

RESULTS

In 19 patients a total of 11 vaginal, 7 intravesical and 5 urethral erosions occurred. Mean patient age was 52 years (range 32 to 69) and average followup was 8.4 months (range 3 to 34). Average time from symptom onset to sling removal was 10.1 months (range 1.5 to 38). Of the 19 patients 14 (74%) presented with multiple symptoms. Symptoms varied, including refractory pain, recurrent infections and bladder storage/emptying dysfunction. Urodynamic studies were abnormal preoperatively and postoperatively in 9 of 13 (69%) and 4 of 6 patients (67%), respectively. Following surgery lower urinary tract symptoms resolved completely in only 4 of the 19 patients (21%). Stress incontinence recurred in 8 of the 19 patients (42%). Five patients underwent simultaneous pubovaginal sling, of whom none had recurrent stress urinary incontinence. Only 9 patients (47%) considered themselves dry with no pads following surgery. Four patients required further surgery for refractory voiding symptoms.

CONCLUSIONS

Voiding dysfunction is not an uncommon finding after sling excision in the setting of genitourinary erosion. It may cause additional patient morbidity.

How common are tape erosions? A comparison of two versions of the transobturator tension-free vaginal tape procedure

OBJECTIVE

To compare two transobturator suburethral tapes (Obtape, Mentor-Porges and TVT-O, Gynaecare, Johnson and Johnson) used in the management of urodynamic stress incontinence (USI), for tape erosion (vaginal/urethral) rates, clinical presentation, management and outcome.

PATIENTS AND METHODS

We retrospectively studied women who underwent a transobturator suburethral tension-free vaginal tape (TVT) procedure for managing USI in a tertiary referral centre in the West of Scotland over a 36-month period. In our department, the transobturator approach has been the first-choice approach for TVTs since July 2003. Two types of tapes were mainly used, Obtape and TVT-O, and the choice of tape was primarily decided by the surgeons' preference.

RESULTS

In all, 316 women had a transobturator tape procedure, of which 96 were associated with another procedure; 112 women had TVT-O using the 'inside-out' technique and 204 had the 'outside-in' technique. Of the latter, 192 had Obtape, four had Obtryx (Boston Scientific) and eight had Monarc (American Medical Systems Inc.) tapes. Sixteen women developed vaginal tape erosion, and significantly more were in the Obtape group than in the TVT-O group (7.29% vs 1.78%, P = 0.038). The patients' age, body mass index, previous vaginal surgery and concomitant vaginal surgery were not significant risk factors for erosions. The time between surgery and diagnosis of erosion was 1-45 weeks, with only one patient being asymptomatic; all others presented with clinical symptoms such as vaginal bleeding, discharge and dyspareunia. Thirteen patients were continent at presentation and 10 of these remained continent after surgical management. In the TVT-O group the erosions were in the lateral vaginal wall, while in the Obtape group the erosions were in the form of central tape extrusion secondary to defective vaginal wall healing.

CONCLUSION

There were significantly more vaginal tape erosions in the Obtape group than in the TVT-O group. No cases of urethral erosions were identified.

Severe soft tissue infection of the thigh after vaginal erosion of transobturator tape for stress urinary incontinence

Since the beginning of use of synthetic midurethral slings, several complications, usually benign, have been reported. Recently, three consecutive cases of severe thigh infection secondary to transobturator insertion of a synthetic tape alarmed us. This is a case report about these three cases and a review of literature about complications of transobturator tapes.

Urethrovaginal fistula—a rare complication after the placement of a suburethral sling (IVS)

A sixty-year-old woman with stress urinary incontinence had undergone a placement of an IVS (Tyco Health Care UK) in another hospital in February 2003. Seventeen months after the procedure, she complained about a suppurative discharge from the vagina and a recurrent severe stress urinary incontinence. The gynecological examination revealed an erosion of the sling into the vagina and a large urethrovaginal fistula bordered by granuloma. After removal of the sling, the urethrovaginal fistula was closed using a vaginal flap. A subsequent conservative treatment regime with duloxetine and pelvic floor training improved the stress urinary incontinence to the patient's satisfaction.