Time to rethink: an evidence-based response from pelvic surgeons to the FDA Safety Communication: "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse"

Puerarin-Loaded Electrospun Patches with Anti-Inflammatory and Pro-Collagen Synthesis Properties for Pelvic Floor Reconstruction

Pelvic organ prolapse (POP) is one of the most common pelvic floor dysfunction disorders worldwide. The weakening of pelvic connective tissues initiated by excessive collagen degradation is a leading cause of POP. However, the patches currently used in the clinic trigger an unfavorable inflammatory response, which often leads to implantation failure and the inability to simultaneously reverse progressive collagen degradation. Therefore, to overcome the present challenges, a new strategy is applied by introducing puerarin (Pue) into poly(l-lactic acid) (PLLA) using electrospinning technology. PLLA improves the mechanical properties of the patch, while Pue offers intrinsic anti-inflammatory and pro-collagen synthesis effects. The results show that Pue is released from PLLA@Pue in a sustained manner for more than 20 days, with a total release rate exceeding 80%. The PLLA@Pue electrospun patches also show good biocompatibility and low cytotoxicity. The excellent anti-inflammatory and pro-collagen synthesis properties of the PLLA@Pue patch are demonstrated both in vitro in H2O2-stimulated mouse fibroblasts and in vivo in rat abdominal wall muscle defects. Therefore, it is believed that this multifunctional electrospun patch integrating anti-inflammatory and pro-collagen synthesis properties can overcome the limitations of traditional patches and has great prospects for efficient pelvic floor reconstruction.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

The double-edged sword of mesh use in pelvic organ prolapse surgery: a case report

Introduction

Pelvic organ prolapse (POP) is a prevalent condition among parous women, often warranting surgical intervention. This case accentuates the complications associated with mesh in POP surgeries, iterating the imperative need for an evidence-based approach towards its utilization and exhaustive patient counselling.

Case presentation

A 60-year-old female, post-mesh-augmented POP repair, embarked on a 13-year journey characterized by persistent pelvic pain and multiple interventions. Despite undergoing several surgeries across different countries, involving mesh and stone removals, her symptoms, notably pelvic pain and dyspareunia, persisted. Clinical examinations revealed mesh erosion into the perivesical tissue, bladder, and associated stones, which were addressed through multiple interventions, albeit with transient success.

Discussion

The complex journey of this patient exemplifies the intricate challenges mesh poses in POP surgeries. While mesh application offers a minimally invasive approach and has proven successful in numerous cases, it simultaneously opens a Pandora's box of potential severe complications, necessitating thorough patient counselling and post-surgery management.

Conclusion

The case delineates the challenging path that clinicians and patients tread when navigating through mesh-associated complications post-POP repair. Although mesh has been heralded as a revolutionary approach in POP surgeries, its potential drawbacks necessitate judicious application, ensuring clinicians are well-versed with its associated risks and are adept in managing ensuing complications.

Induction of a different immune response in non-titanized compared to titanized polypropylene meshes

It is well known that pelvic organ prolapse (POP) significantly reduces the quality of life of affected women and in many cases requires corrective surgery. Aim of the study was to compare the immune response against titanized versus non-titanized meshes, especially macrophage polarization and immune checkpoint association. For this, we analyzed 644 POP surgeries, which were performed between 2017 and 2022, in our department. Four of them needed revision surgery caused by erosion. We analyzed the influx of CD68 & CD163 positive macrophages and the expression of immune checkpoint molecules PD-L1 and PD1 in these 4 patients. We identified a large number of CD68 and CD163 positive macrophages and additionally a PD-L1 expression of these cells. Based on the in-vivo results, we isolated monocytes and co-cultivated monocytes with different mesh material covered with or without fibroblasts. We identified a significantly enhanced macrophage activation and PD-L1 expression in macrophages surrounding non-titanized polypropylene mesh material. Encapsulation of the material by fibroblasts was crucial for that. Specifically, CD68-positive macrophages are upregulated (p < 0.001), co-expressing PD-L1 (p < 0.001) in monocytes co-cultivated with non-titanized polypropylene meshes. Monocytes co-cultivated with titanized polypropylene meshes showed significantly lower expression of CD163 (p = 0.027) and PD-L1 (p = 0.022). In conclusion, our in vitro data suggest that the titanium coating leads to a decreased polarization of macrophages and to a decreased immune response compared to non-titanized meshes. This could be an indication for the increased incidence of erosion of the non-titanized meshes, which is a severe complication of this procedure and requires revision surgery. STATEMENT OF SIGNIFICANCE: Pelvic organ prolapse is a well-known problem for women and often requires corrective surgery. Polypropylene meshes are often used, which differ in their coating (titanized vs. non-titanized). A severe side effect of these surgeries is mesh erosion, due to onset of inflammation, which requires revision surgery. We examined all erosion cases (4 of 644 patients) with implanted nontitanium-coated meshes by immunohistochemistry and found upregulation of macrophage polarization (as markers CD68 and CD163) and increased expression of the immune checkpoint molecules PD-L1 and PD1. This suggests inflammatory processes and an enhanced immune response. In addition, we set up an in vitro experiment to investigate whether coating plays a role. Here, we demonstrated that the non-titanized meshes elicited a significantly higher immune response in comparison to titanized meshes, which could lead to the higher erosion rate of the non-titanized meshes. Our results highlight the benefit of titanized meshes, which should lead to a lower revision surgery rate and thus improved patient outcome.

Anterior and Apical Prolapse: Comparison of Vaginal Mesh Surgery to Vaginal Surgery with No Mesh

Aim of the study: The aim of this study was to evaluate the anatomical results after an anterior sacrospinous ligament fixation (ASSLF) with native tissue repair (anterior colporraphy and apical suspension with prolene) compared to mesh repair for the correction of anterior prolapse at 12 months after surgery. Materials and methods: A monocentric prospective study comparing two similar cohorts who underwent ASSLF was conducted. The primary endpoint was the gain in the position of the Ba point relative to its position before surgery and twelve months after surgery. The secondary endpoints consisted of objective results, which were assessed using validated questionnaires. Results: Fifty-three women were included in the native tissue repair group between June 2019 and March 2020. They were compared to 53 women operated on with anterior and apical mesh. There was no difference with respect to the Ba point after 1 year between the two groups (−2 [−3; 1.5]; −2 [−3; 1], p = 0.9789). The apex was significantly better corrected in the native tissue repair group (−7 vs. −6, p = 0.0007). There was also a better correction on the rectocele in the native tissue repair group (−3 vs. −2, p = 0.0178). The rate of Stage 2 anterior vaginal prolapse at one year was approximately 30% in both groups (no statistical difference). Conclusions: ASSFL without mesh does not increase the risk of cystocele recurrence at 1 year after surgery. A future prospective comparison of this native tissue repair technique with mesh suspension is necessary to explore these preliminary findings.

Long-term outcomes of cable-suspended suture technique versus conventional suture for anterior vaginal wall prolapse: a retrospective cohort study

BACKGROUND

Anterior colporrhaphy (AC) is a conventional surgical repair technique for cystocele but with high recurrence rate. We present a novel technique: Cable-suspended structure (CSS) by non-absorbable suture combined with "bridge" formation in surgical treatment of cystocele. This study aimed to evaluate and compare the long-term outcome of CSS technique for anterior vaginal wall repair with AC.

METHODS

A retrospective review was performed on patients who underwent anterior vaginal wall repair between January 2012 and March 2017 at our center. All the patients were under a follow-up survey. The primary outcomes were objective cure (anterior prolapse POP-Q ≤ stage 1) and subjective cure (no symptoms of bulge or retreatment for prolapse). Secondary outcomes included quality of life (QOL) and patients' satisfaction, outcomes of site-specific POP-Q points Aa, Ba and C, as well as postoperative complications.

RESULTS

Of 91 included participants, 43 underwent AC and 48 underwent CSS. The proportion of sarcrospinous ligament fixation in the CSS group was higher than in the AC group (81.4% vs. 77.1%, P < 0.05). At a median follow-up of 69 months, the CSS group showed significantly higher objective cure rate compared with the AC group (72.9% vs. 51.2%, odds ratio 2.57, 95%CI 1.07-6.16). After adjusting for sarcrospinous ligament fixation, the CSS group still significantly showed higher objective cure rate (adjusted odds ratio 2.88, 95%CI 1.16-7.21). The proportion of the patients with POP-Q 0 stage in the CSS group was particularly higher than the AC group (25% vs. 7.0%, P = 0.025). There was no difference between the groups with respect to subjective cure, patients' satisfaction and postoperative complication.

CONCLUSIONS

The CSS technique showed better objective outcome than AC, however, subjective cure rate did not significantly differ between the two. Future prospective trial with large-scale should confirm the effectiveness and safety of CSS in sexually active women.

Evaluation of surgical treatment of genital prolapse using synthetic mesh in an outpatient procedure and patient satisfaction

OBJECTIVE

- To study a new strategy for one day prolapse surgery with mesh, to identify risk factors for one day procedure failure and patient satisfaction.

METHODS

- This retrospective observational study was conducted at Saint Etienne University Hospital, France. All patients who received a prolapse treatment by synthetic mesh between January 2016 and April 2019 in one day surgery procedure were included in the study. Exhaustive variables was collected and all patients were contacted for a satisfaction survey.

RESULTS

- During the periode patients were included. 6 of them required readmissions included 5 hospitalization for urinary retention and 1 for abnormal bleeding. Among the patients, 87% were satisfied. Only the anesthetic management was significantly associated with an ambulatory surgery success (p = 0,02) and satisfaction (p = 0,001).

CONCLUSION

- This study shows the technical feasibility and safety of prosthetic prolapse surgery during outpatient hospitalization. The success of a rapid pathway in one day surgery depends on a good selection of patients, proper planning of surgical procedures and optimization of anesthesia protocols. The prevention of outpatient failures is justified for medical and economic reasons respecting the quality and safety of patients.

Comparison of Surgical Results and Postoperative Recurrence Rates by Laparoscopic Sacrocolpopexy with Other Surgical Procedures for Managing Pelvic Organ Prolapse

Objectives:

Pelvic organ prolapse (POP) is relatively high for a gynecologic disease. Laparoscopic sacrocolpopexy (LSC) is currently the main surgical option for managing POP. The priority of the surgical treatment is preventing recurrence after the surgery. We presented the surgical outcome and recurrence rate of LSC and compared the data of LSC with that of other surgical procedures for managing POP to examine the effectiveness of LSC over other them.

Materials and Methods:

We compared the results of 138 cases of LSC with other conventional procedures, namely 30 cases of total vaginal hysterectomy (TVH) combined with colporrhaphy anterior and posterior, 66 cases of the Manchester operation, and 68 cases of colpocleisis. We compared the age, body mass index, operative time, blood loss volume, postoperative hospital stay duration, rate of complications, recurrence rate, reoperation rate, and the cumulative recurrence rate after 10 years.

Results:

The complication rate of LSC, TVH, the Manchester operation, and colpocleisis was 2.2%, 3.3%, 3.0%, and 4.4%; the recurrence rate 2.8%, 3.5%, 4.5%, and 8.7%; and the cumulative recurrence rate after 10 years 3.7%, 4.6%, 8.8%, and 18.2%. There was no significant difference between LSC and the other three groups.

Conclusion:

LSC seems to be an effective surgical option that requires a higher skill level than other surgical methods and has a longer operative time, lesser operative invasion, and a lower long-term recurrence rate. We will actively recommend LSC to those when appropriate.

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis

Background

Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material.

Methods

A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment.

Results

Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0–0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5–1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0–15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3–8.1) and 5.8% (95% CI 2.9–9.6), respectively. The clinical and statistical heterogeneity was high.

Conclusions

No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

Evaluating tissue-engineered repair material for pelvic floor dysfunction: a comparison of in vivo response to meshes implanted in rats

INTRODUCTION AND HYPOTHESIS

Achieving better anatomic restoration and decreasing the associated complications are necessary for material repair of pelvic floor dysfunction (PFD). This study was aimed to investigate host response to tissue-engineered repair material (TERM) in rat models by comparing different materials and study the changes in biomechanical properties over time.

METHODS

TERM was constructed by seeding adipose-derived stem cells (ADSCs) on electrospun poly(L-lactide)-trimethylene carbonate-glycolide (PLTG) terpolymers. The TERM, PLTG, porcine small intestine submucosa mesh (SIS), and polypropylene (PP) (n = 6 / group per time point) were implanted in rats for 7, 30, 60, and 90 days. Hematoxylin-eosin and Masson's trichrome staining were used to assess the host response, and mechanical testing was used to evaluate the changes in biomechanical properties.

RESULTS

In vivo imaging showed that the ADSCs were confined to the abdominal wall and did not migrate to other organs or tissues. The TERM was encapsulated by a thicker layer of connective tissue and was associated with less reduced inflammatory scores compared with PLTG and PP over time. The vascularization of the TERM was greater than that with PP and PLTG over time (p < 0.05) and was greater than that with SIS on day 90. The ultimate tensile strain and Young's modulus of the PP group showed the greatest increases, and the TERM group followed on day 90.

CONCLUSIONS

This TERM achieved better host integration in rat models and better biomechanical properties, and it may be an alternative material for PFD.

Autologous fascial slings remain viable at long-term follow-up: a post cystectomy case report

Background

Autologous fascial slings (AFS) have been used for a very long time in the treatment of female stress urinary incontinence, but the introduction of synthetic mesh slings placed either retropubicallyor trans-obturator has decreased the need to harvest the autologous rectus muscle fascia, thus reducing invasiveness and operative time. However AFS are still indicated in complicated cases and re-interventions, and the FDA has underlined safety concerns over the use of surgical meshes for the transvaginal repair of prolapsed pelvic organs.

Case presentation

A 76-year-old woman with muscle-invasivebladder cancer underwent radical cystectomy 16 years after retropubic positioning of an autologous rectus muscle fascial sling for SUI, with complete symptom resolution. The sling was easily identified and removed en bloc with the bladder and urethra, providing an opportunity to histologicallyevaluate the autologous fascial graft after its long permanence in the new position. Histopathological examination demonstrated increased fibroblastic proliferation and formation of capillaries. A slight separation and an increased waviness of the connective fibers were both evident. An increased vascularity was also apparent, including transverse vessels, with clusters of vessels. A relative inflammatory reaction was present in over 300 cells/10 HPF. All these characteristics indicated viable connective tissue.

Conclusions

AFS remain a valuable surgical option for both primary and recurrent SUI in women, showing high cure rates and low complications in the long-term. The present case, to the best of our knowledge, presents the longest follow-up period of an autologous rectus muscle fascia placed retropubically and its histological evaluation documents characteristics which support its mechanical strength and viability.

A 14-year multi-institutional collaborative study of Chinese pelvic floor surgical procedures related to pelvic organ prolapse

BACKGROUND

It has been a global trend that increasing complications related to pelvic floor surgeries have been reported over time. The current study aimed to outline the development of Chinese pelvic floor surgeries related to pelvic organ prolapse (POP) over the past 14 years and investigate the potential influence of enhanced monitoring conducted by the Chinese Association of Urogynecology since 2011.

METHODS

A total of 44,594 women with POP who underwent pelvic floor surgeries between October 1, 2004 and September 30, 2018 were included from 22 tertiary academic medical centers. The data were reported voluntarily and obtained from a database. We compared the proportion of each procedure in the 7 years before and 7 years after September 30, 2011. The data were analyzed by performing Z test (one-sided).

RESULTS

The number of different procedures during October 1, 2011-September 30, 2018 was more than twice that during October 1, 2004-September 30, 2011. Regarding pelvic floor surgeries related to POP, the rate of synthetic mesh procedures increased from 38.1% (5298/13,906) during October 1, 2004-September 30, 2011 to 46.0% (14,107/30,688) during October 1, 2011-September 30, 2018, whereas the rate of non-mesh procedures decreased from 61.9% (8608/13,906) to 54.0% (16,581/30,688) (Z = 15.53, P < 0.001). Regarding synthetic mesh surgeries related to POP, the rates of transvaginal placement of surgical mesh (TVM) procedures decreased from 94.1% (4983/5298) to 82.2% (11,603/14,107) (Z = 20.79, P < 0.001), but the rate of laparoscopic sacrocolpopexy (LSC) procedures increased from 5.9% (315/5298) to 17.8% (2504/14,107).

CONCLUSIONS

The rate of synthetic mesh procedures increased while that of non-mesh procedures decreased significantly. The rate of TVM procedures decreased while the rate of LSC procedures increased significantly.

TRIAL REGISTRATION NUMBER

NCT03620565, https://register.clinicaltrials.gov.

Measures for Safe Laparoscopic Sacrocolpopexy: Preoperative Contrast-Enhanced Computed Tomography and Perioperative Ultrasonography

Laparoscopic sacrocolpopexy is one of the most difficult laparoscopic surgical techniques. In this study, we report on our efforts to safely perform this procedure, which consists of suturing a piece of mesh onto the anterior longitudinal ligament using a nonabsorbent suture during mesh fixation onto the prepromontorium layer, which can lead to massive bleeding if a mistake is made, by performing preoperative and intraoperative image evaluation. Preoperative contrast-enhanced computed tomography was performed. Images in DICOM format were acquired, and three-dimensional vessel reconstruction was performed. After performing a peritoneal incision in the presacral area, ultrasonography was performed using a probe inserted through a 12-mm trocar into the abdominal cavity to re-confirm the absence of vessels near the planned suturing area. After ultrasonography, an Ethibond^® suture was inserted through the anterior longitudinal ligament. In our hospital, 126 patients underwent the procedure, and none had a serious hemorrhage or required blood transfusion, indicating the safety of this modified procedure without separation of a wide presacral area. We believe that these techniques can be performed safely with minimal incision. However, we did not examine the efficacy of these techniques in this paper. Further studies are needed to determine whether this approach is suitable.

Negative pressure wound therapy for burn patients: A meta-analysis and systematic review

Negative pressure wound therapy (NPWT), which has been applied in various medical specialties to accelerate wound healing, has been the object of a few investigations. We explored the effectiveness of NPWT and the possibility of its inclusion in burn management guidelines. Randomised controlled trials comparing NPWT with non-NPWT treatments for burn wounds were extracted from PubMed. For the risk of bias analysis, all included studies were evaluated according to the Cochrane risk of bias tool and the approaches outlined in the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) Handbook. Outcomes such as graft take rate in the first week, infection rate, and overall complication rate were analysed. Six studies that included a total of 701 patients met our inclusion criteria. Qualitative analysis revealed that the NPWT group had a significantly better overall graft rate in the first week (P = 0.001) and a significantly lower infection rate (P = 0.04). No significant difference in the overall complication rate was found. Our results indicate that NPWT is a safe method for stimulating healing and lowering the infection rate of burn wounds. NPWT can be part of general burn management, and its incorporation into burn treatment guidelines is recommended.

Consensus statement of the Spanish Association Of Urology on the use of meshes in pelvic organ prolapse

INTRODUCTION

Recently the Food and Drug Administration has banned the use of transvaginal meshes for the surgical treatment of pelvic organ prolapse (POP) in the United States. This has caused a worldwide impact on the management of pelvic floor pathology by different specialists.

OBJECTIVE

To achieve a consensus on the use of meshes in the surgical treatment of POPs.

ACQUISITION OF DATA/EVIDENCE

A Committee of experts of the Spanish Association of Urology (AEU) was organized to review the literature and analyze the safety and efficacy of the use of polypropylene meshes in POP surgery.

RESULTS/EVIDENCE FROM THE LITERATURE

The evidence reflects that the use of meshes, compared to the use of native tissues, offers better efficacy at the expense of new complications and a higher rate of surgical reviews, these being minor in the hands of expert surgeons.

CONCLUSIONS

POP surgery must be performed by experienced surgeons, properly trained and in referral centers. The patient should receive correct information about the different treatment options. Transvaginal meshes should only be indicated in complex cases and in recurrences after POP surgery.

AEU PROPOSAL

Creation of a clinical guideline and a national registry for long-term evaluation. Preparation of an Informed Consent available to all professionals and patients, as well as a specific training plan to achieve better training in complex pelvic floor surgery.

A novel antibacterial biomaterial mesh coated by chitosan and tigecycline for pelvic floor repair and its biological performance

The biomaterials composed of mammalian extracellular matrix (ECM) have a great potential in pelvic floor tissue repair and functional reconstruction. However, bacterial infection does cause great damage to the repair function of biomaterials which is the major problem in clinical utilization. Therefore, the development of biological materials with antimicrobial effect is of great clinical significance for pelvic floor repair. Chitosan/tigecycline (CS/TGC) antibacterial biofilm was prepared by coating CS/TGC nanoparticles on mammalian-derived ECM. Infrared spectroscopy, scanning electron microscopy, bacteriostasis circle assay and static dialysis methods were used to characterize the membrane. MTS assay kit and DAPI fluorescence staining were used to evaluate cytotoxicity and cell adhesion. The biocompatibility was assessed by subabdominal implantation model in goats. Subcutaneous antimicrobial test in rabbit back was used to evaluate the antimicrobial and repairing effects on the infected wounds in vivo. Infrared spectroscopy showed that the composite coating had been successfully modified. The antibacterial membrane retained the main structure of ECM multilayer fibers. In vitro release of biomaterials showed sustained release and stability. In vivo studies showed that the antibacterial biological membrane had low cytotoxicity, fast degradation, good compatibility, anti-infection and excellent repair ability.

Current Overview of Surgical Options for Female Stress Urinary Incontinence

Stress urinary incontinence (SUI) is a highly prevalent health condition that significantly impacts the quality of life. Traditional methods of treatment for SUI, such as pubovaginal sling and Burch colposuspension, have been replaced by the midurethral sling because of its high efficacy, low complication and morbidity rates, and short learning curve. Although multiple behavioral and operative treatments exist, midurethral slings are the gold standard for the treatment of SUI in women. However, several reports have raised concerns about complications caused by the synthetic mesh used in midurethral slings. Therefore, surgical treatment for SUI in women must be chosen with care, taking into account potential complications. Herein, we review the current safety issues pertaining to the use of meshes, the efficacy of traditional surgeries, old and new midurethral slings, and recent data comparing the efficacy and safety of different surgical options. This review is aimed at developing practical guidelines for choosing surgical options for women with SUI.

"Central Road" cystoscopic finding: The road to worsened incontinence following laparoscopic sacrocolpopexy

INTRODUCTION

This paper presents the "Central Road" cystoscopic finding accompanied by magnified mixed urinary incontinence following laparoscopic sacrocolopopexy.

CASE PRESENTATION

A 70-year-old female experienced severe mixed urinary incontinence upon completing laparoscopic sacrocolopopexy. The cystoscopy showed a cord-like appearance in the center of the bladder trigon and posterior wall. Videourodynamics confirmed stress urinary incontinence, and chain cystourethrography indicated that the proximal urethra was open and the posterior vesicourethral angle was atypically widened. After implanting a midurethral sling, mixed urinary incontinence was cured subjectively and objectively without medication.

CONCLUSION

The "Central Road" cystoscopic finding can be a signpost pointing to laparoscopic sacrocolopopexy mesh overtensioning, which can cause dekinking of the bladder neck, exacerbate stress urinary incontinence, and possibly lead to stress-induced instability. A midurethral sling successfully relieved mixed urinary incontinence in this case, but it might be necessary to loosen the laparoscopic sacrocolopopexy mesh in some other cases.

Multidisciplinary management of women with pelvic organ prolapse, urinary incontinence and lower urinary tract symptoms.A clinical and psychological overview

Although female sexual dysfunctions are common among women with urogynecological conditions, they have not been thoroughly studied and there are still many questions without an answer. The recent evidence on sexual disorders in women with urogynecological diseases shows a quite wide spectrum of therapeutic approaches, which require the physicians to take into account not only the primary symptoms, but also all the associated factors negatively affected. It has been widely underlined that gynecological diseases are often associated with high stress and have a negative impact on quality of life and psychological well-being of women affected. For this reason, a multidisciplinary approach for the management of these diseases is highly recommended. Also in the case of urogynecological disorders, it is important to take into account psychological outcomes throughout the diagnostic and therapeutic process. In the light of these considerations, the aim of this short review is to evaluate the impact of the main urogynecological diseases and the currently available therapeutic options in order to improve quality of life and sexuality of these patients and to stress the need for a multidisciplinary approach in order to minimize the negative consequences of these diseases for the sexual well-being of women and their partners.

3D bioprinted endometrial stem cells on melt electrospun poly ε-caprolactone mesh for pelvic floor application promote anti-inflammatory responses in mice

Endometrial mesenchymal stem/stromal cells (eMSCs) exhibit excellent regenerative capacity in the endometrial lining of the uterus following menstruation and high proliferative capacity in vitro. Bioprinting eMSCs onto a mesh could be a potential therapy for Pelvic Organ Prolapse (POP). This study reports an alternative treatment strategy targeting vaginal wall repair using bioprinting of eMSCs encapsulated in a hydrogel and 3D melt electrospun mesh to generate a tissue engineering construct. Following a CAD, 3D printed poly ε-caprolactone (PCL) meshes were fabricated using melt electrospinning (MES) at different temperatures using a GMP clinical grade GESIM Bioscaffolder. Electron and atomic force microscopies revealed that MES meshes fabricated at 100 °C and with a speed 20 mm/s had the largest open pore diameter (47.2 ± 11.4 μm) and the lowest strand thickness (121.4 ± 46 μm) that promoted optimal eMSC attachment. An Aloe Vera-Sodium Alginate (AV-ALG) composite based hydrogel was optimised to a 1:1 mixture (1%AV-1%ALG) and eMSCs, purified from human endometrial biopsies, were then bioprinted in this hydrogel onto the MES printed meshes. Acute in vivo foreign body response assessment in NSG mice revealed that eMSC printed on MES constructs promoted tissue integration, eMSC retention and an anti-inflammatory M2 macrophage phenotype characterised by F4/80⁺CD206⁺ colocalization. Our results address an unmet medical need highlighting the potential of 3D bioprinted eMSC-MES meshes as an alternative approach to overcome the current challenges with non-degradable knitted meshes in POP treatment. STATEMENT OF SIGNIFICANCE: This study presents the first report of bioprinting mesenchymal stem cells derived from woman endometrium (eMSCs) to boost Pelvic Organ Prolapse (POP) treatment. It impacts over 50% of elderly women with no optimal treatment at present. The overall study is conducted in three stages as fabricating a melt electrospun (MES) mesh, bioprinting eMSCs into a Ca²⁺ free Aloe Vera-Alginate (AV-Alg) based hydrogel and in vivo study. Our data showed that AV-ALG hydrogel potentially suppresses the foreign body response and further addition of eMSCs triggered a high influx of anti-inflammatory CD206⁺ M2 macrophages. Our final construct demonstrates a favourable foreign body response to predict expected tissue integration, therefore, provides a potential for developing an alternative treatment for POP.

Observational analysis of mesh related complications in urogynecologic procedures

Since the 1990s, the use of mesh has expanded in gynecologic surgeries in the aim of correcting pelvic organ prolapse. Because there has been a lot of complications that were reported, the U.S. Food and Drug Administration has requested the withdrawal of many products from the market. Recently, many countries have called for the suspension of vaginal mesh products from the market. The objective of this review is to analyze the incidence of the complications that arise after vaginal mesh surgeries with an insight to the American College of Obstetricians and Gynecologists recommendations on the management of those complications.

Novel Incision-free Device for Transvaginal Apical Pelvic Organ Prolapse Repair

STUDY OBJECTIVE

The purpose of this study was to present the feasibility and potential clinical advantages of Apyx (Escala Medical, Israel), a minimally invasive incision-free anchoring device, for apical prolapse repair.

DESIGN

An experimental prospective animal and cadaver study.

SETTING

Animal facility and a cadaver laboratory of a tertiary care teaching hospital.

PATIENTS

Included in this study were 7 ovine models, 2 porcine specimens, and 3 fresh unembalmed female human cadavers.

INTERVENTIONS

The Apyx device for sacrospinous ligament (SSL) suspension was tested on ovine and porcine models. The pullout force needed to detach the Apyx anchor from the SSL was measured. Safety, reliability, and feasibility of this new incision-free procedure were also tested on an ovine model and human cadavers. The precision in deployment of the Apyx device to the SSL was tested via palpation by the surgeon, tissue dissection, and x-ray imaging. The efficacy was tested both by pullout forces and histologic analysis of the vaginal attachment to the SSL.

MEASUREMENTS AND MAIN RESULTS

Forty-two anchors were inserted into the SSLs on ovine and porcine models and on cadaver SSLs. No abnormalities or malfunctions were noted in the functional performance of the anchors or the retrieval device. Mean pullout force for the ovine animal model was 38.64 ± 2.80 N. Pullout force in the porcine model was found to be in correlation with the values observed in the ovine model. None of the measured forces was below 20 N. Accuracy and safety tests showed good consistency when deploying the Apyx device to the SSL with no damage to surrounding organs in the ovine or the human cadaver model. Histology demonstrated biologic adhesion characterized by a gross assessment of a newly formed, firm fibrotic tissue 12 weeks after anchor deployment.

CONCLUSION

The Apyx anchoring system, a novel incision-free minimally invasive prolapse repair device, demonstrated an anatomically feasible, easy-to-use procedure for suspending the vaginal apex to the SSLs. Its clinical safety, efficacy, and impact on patient symptoms and quality of life should be further studied.

Laparoscopic Sacrocolpopexy Plus Colporrhaphy With a Small Intestine Submucosa Graft Versus Total Pelvic Floor Reconstruction for Advanced Prolapse: A Retrospective Cohort Study

Purpose

Transvaginal mesh (TVM) results in a greater anatomic cure but more complications. We aimed to compare laparoscopic sacrocolpopexy (LSC) plus colporrhaphy with the small intestine submucosa (SIS) graft versus TVM for advanced pelvic organ prolapse (POP).

Methods

Patients with advanced POP who underwent LSC plus colporrhaphy with the SIS graft or TVM at a center between September 2015 and November 2016 were studied. Anatomical outcomes were evaluated using POP quantification. Functional outcomes related to POP and sexual life were evaluated using the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student t -tests were used for 2 independent samples.

Results

A total of 76 patients were enrolled in this study with 26 patients in the LSC plus colporrhaphy with the SIS graft group (group A) and 50 patients with TVM group (group B). All patients in both groups demonstrated significant improvement in anatomical outcomes (P<0.05) after surgery. PFDI-20 scores were significantly improved 12 months after operation in both groups (P<0.001). PISQ-12 scores were significantly improved in patients after surgery, especially patients in group A (P<0.001). Mesh exposure occurred in both groups as follows: 8 patients (30.7%) in group A and 5 patients (10%) in group B.

Conclusions

Even though both surgeries showed excellent results for subjective and objective outcomes, the use of an SIS graft might increase the exposure of polypropylene mesh. We do not recommend LSC plus colporrhaphy with the SIS graft for advanced multiple-compartments prolapse.

Efficacy and safety of the Calistar and Elevate anterior vaginal mesh procedures

OBJECTIVES

The pelvic organ prolapse (POP) surgery with implantation of anterior transvaginal mesh (e.g. Elevate or Calistar) may provide objective and subjective improvement as compared to traditional POP repair without mesh. Given differences between the Elevate and the Calistar mesh and their different placement methods, some variation inlong-term clinical outcomes of these anterior vaginal mesh procedures can be expected.

STUDY DESIGN

The purpose of the study was to compare the 18-month operative success in patients who had undergone anterior POP surgery with either the Calistar (n = 54) or Elevate mesh (n = 50).

RESULTS

There were no between-group differences in objective measures of operative efficacy, including POP-Q anterior stage 0 or I (94% for Calistar, 92% for Elevate) and "no descent beyond the hymen" (98% for Calistar, 94% for Elevate). The proportion of patients with subjective measure of operative efficacy (no vaginal bulge symptoms) did not differ between the groups (91% for Calistar, 78% for Elevate). There were no between-group differences in the proportion of women suffering from vaginal exposure, de novo stress urinary incontinence (SUI), de novo overactive bladder (OAB) symptoms, pelvic floor pain or dyspareunia. The operative cure of OAB symptoms was similar in the groups. The proportion of patients with the operative cure of SUI symptoms was significantly higher in the Calistar as compared to the Elevate group.

CONCLUSIONS

The results suggestthat the Calistar system offers similar efficacy in the treatment of anterior and both anterior and apical POP as compared to the Elevate. The use of anterior Calistar is associated with some additional benefits, i.e. SUI treatment in patients with concomitant anterior and both anterior and apical POP and SUI symptoms.

Rate of Pelvic Organ Prolapse Surgery Among Privately Insured Women in the United States, 2010-2013

OBJECTIVE

To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh.

METHODS

This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis.

RESULTS

Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively.

CONCLUSION

Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.

A multipurpose uterine/vaginal manipulator for laparoscopic urogynecologic procedures

INTRODUCTION AND HYPOTHESIS

The use of an appropriate uterine manipulator is key to various laparoscopic gynecologic procedures. Adequate uterine manipulation is important for total or supracervical laparoscopic hysterectomies, laparoscopic sacrocolpopexy as well as laparoscopic repair of vaginal vault prolapse. While several uterine manipulators are available to choose from, their use may be specific to certain procedures and their cost may vary as well.

METHODS

This video aims to provide an introduction to a multipurpose, reusable uterine/vaginal manipulator that can be used for laparoscopic supracervical hysterectomy, laparoscopic sacrocolpopexy, laparoscopic hysteropexy as well as laparoscopic repair of vaginal vault prolapse.

RESULTS

The video highlights the user-friendly, easy-to-clean, reusable, multipurpose uterine/vaginal manipulator.

CONCLUSIONS

The manipulator is designed for an efficient combination of laparoscopic urogynecologic procedures and supracervical hysterectomy.

Rectal mesh erosion after posterior vaginal kit repair

INTRODUCTION AND HYPOTHESIS

The present video shows a rare case of erosion through the full rectal wall into the rectum after a transperineal implant of a double-arm polypropylene kit.

METHODS

A 70-year-old woman underwent a transperineal implant of a double-arm polypropylene kit. One year after surgery, she developed bothersome symptoms in the posterior perineum including heaviness, pain and rectal bleeding during defecation. A clinical examination showed the presence of a part of the prothesis traversing the rectal cavity. A minimally invasive transanal approach was performed to remove the mesh and restore the rectal integrity.

RESULTS

This surgical technique demonstrates rectal mesh removal with a transanal approach.

CONCLUSIONS

To our knowledge, this is a rare complication of rectal erosion of a posterior transperineal mesh kit. The aim of this video is to show a complete transanal approach to treating this serious complication avoiding the more invasive and traumatic abdominal procedure.

Comparison of UpholdTM Vaginal Mesh Procedure with Hysterectomy or Uterine Preservation for the Treatment of Pelvic Organ Prolapse

Hysterectomy is the empirical treatment for female pelvic organ prolapse (POP) without robust evidence to prove its efficacy. Uphold transvaginal mesh (TVM) system is an innovated device with smaller area, superior anterior/apical support with single incision to treat POP. The prospective cohort study aims to evaluate Uphold TVM's performance with or without concomitant hysterectomy. Inclusion criteria specify patients suffering from stage 2 or more anterior/apical prolapse without previous hysterectomy. Exclusion criteria specify those with contraindications to uterine preservation, such as leiomyomas, adenomyosis, endometrial hyperplasia, abnormal uterine bleeding, postmenopausal bleeding, cervical dysplasia, receiving tamoxifen treatment, family history of gynecology cancer, or colon cancer and incapability to be routinely followed. Thirty patients are recruited in the hysterectomy group and 66 patients in the hysteropexy group. The results demonstrate that patients with Uphold mesh only experience longer vaginal length, shorter operation duration, less blood loss and less post-operation pain. The performance in anatomical correction, lower urinary tract symptoms improvement, de novo dyspareunia, urodynamic study parameters and mesh extrusion rates are comparable with or without uterus preservation. The information is useful in pre-operation counseling, when the patient can make an educated choice whether or not to receive concomitant hysterectomy.

The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh

INTRODUCTION

Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh.

MATERIALS AND METHODS

Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty.

RESULTS

From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery.

CONCLUSIONS

Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery.

Successful repair of a rectovaginal fistula caused by a tension-free vaginal mesh (TVM): a case report

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

Long-term outcomes of transvaginal mesh (TVM) In patients with pelvic organ prolapse: A 5-year follow-up

OBJECTIVE

The objective of this study was to evaluate the overall outcomes and complication rates of the transvaginal mesh (TVM) placed for the management of pelvic organ prolapse (POP) at 5-years follow up.

STUDY DESIGN

Retrospective cohort study in Urogynecology section in a single center in Argentina. Patients with prolapse stage II or higher were included. Seventy-six patients had TVM surgery for POP and 72 (95%) were available for the 5-year follow-up period.

RESULTS

The cure rate using the combined criteria (leading edge ≤0 according to Pelvic Organ Prolapse Quantification System (POP-Q), no bulge symptoms and no new treatment for prolapse) was 79.2% (57/72) (95% CI 68-88%). Only 5.5% (4/72) (95% CI 1.5-13.6) were re-operated for prolapse recurrence. Mesh exposure occurred in 16.6% of cases (n = 12; 95%CI 8.9-27.3). The incidence of de-novo dyspareunia was 13.3% (2/15) (95%CI 1-40) CONCLUSIONS: We observed that TVM is a durable treatment for prolapse and that adverse events were acceptable without severe complications at 5-year follow-up.

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.

An evaluation of the Manufacturer And User Facility Device Experience database that inspired the United States Food and Drug Administration's Reclassification of transvaginal mesh

Purpose

To assess the utility of the Manufacturer And User Facility Device Experience (MAUDE) database in objectively capturing adverse events for transvaginal mesh in the United States.

Materials and Methods

We reviewed 1,103 individual medical device reports submitted to the MAUDE database that inspired the United States (US) Food and Drug Administration's 2008 Public Health Notification. Entries were compiled into a categorical database that reported manufacturer, brand, reporter type, report source, and type of adverse event.

Results

There were numerous examples of missing, duplicated, and non-standardized entries. Analysis revealed 64 reports with duplicated information, and six reports representing multiple patients. Forty-seven percent of medical device reports did not identify a reporter source. At least 28% of reported devices are no longer on the US market. There was wide variability in the quality and completeness of submitted reports and true adverse event rates could not be accurately calculated because the number of total cases was unknown.

Conclusions

The MAUDE database was limited in its ability to collect, quantify, and standardize real-life adverse events related to transvaginal mesh. While it functions to collect information related to isolated adverse events, systematic limitations of the MAUDE database, that no doubt extend to other medical devices, necessitate the development of new reporting systems. Alternatives are under development, which may allow regulators to more accurately scrutinize the safety profiles of specific medical devices.

Long-term outcome of vaginal mesh or native tissue in recurrent prolapse: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate clinically relevant long-term outcomes of transvaginal mesh or native tissue repair in women with recurrent pelvic organ prolapse (POP).

METHODS

We performed a 7-year follow-up of a randomized controlled trial on trocar-guided mesh placement or native tissue repair in women with recurrent POP. Primary outcome was composite success, defined as absence of POP beyond the hymen, absence of bulge symptoms, and absence of retreatment for POP. Secondary outcomes were adverse events, pain, and dyspareunia. Multiple imputation was used for missing data of composite success and pain; estimates are presented with 95% confidence intervals (CI).

RESULTS

Between August 2006 and July 2008, 194 women were randomized; 190 underwent surgery. At 7 years, 142 (75%) were available for analysis, of whom, the primary outcome could be calculated in 127. Composite success was 53% (95% CI 41, 66) for mesh and 54% (95% CI 42, 65) for native tissue. Repeat surgery for POP was 25% for mesh and 16% for native tissue (difference 9%; 95% CI -5, 23) and occurred in untreated compartments in the mesh group and treated compartments in the native tissue group. Mesh exposure rate was 42%; pain with mesh 39% and native tissue 50% (difference - 11%, 95% CI -27, 6); dyspareunia with mesh 20% and native tissue 17% (difference 3%, 95% CI -9, 17).

CONCLUSIONS

Seven-year composite success rates appeared similar for mesh and native tissue. Mesh did not reduce long-term repeat surgery rates due to de novo POP in nonmesh-treated vaginal compartments. Mesh exposure rates were high, though significant differences in pain and dyspareunia were not detected.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT00372190.

[Implants for genital prolapse : Pro mesh surgery]

There has been an overall increase in pelvic organ prolapse due to demographic changes (increased life expectancy). Increasing sociocultural demands of women require treatments that are more effective with methods that are more successful. In the treatment of pelvic floor insufficiency and uterovaginal prolapse, pelvic floor reconstructions with mesh implants have proven to be superior to conventional methods such as the classic colporrhaphy, reconstructions with biomaterial, and native tissue repair in appropriately selected patients and when applying exact operation techniques, especially because of good long-term results and low recurrence rates. When making a systematic therapy plan, one should adhere to certain steps, for example, a pelvic floor reconstruction should be undertaken before performing the corrective procedure for incontinence. The approach, if vaginal, laparoscopic, or abdominal should be chosen wisely, taking into consideration the required space of action, in such a way that none or only minimal collateral damage related to the operation occurs. The use of instrumental suturing techniques and operation robots are advantageous in the case of difficult approaches and limited anatomical spaces. In principle, the surgeon who implants meshes should be able to explant them! The surgical concept of mesh-related interventions in the pelvis must meet established rules. "Implant as little mesh as possible and only as much suitable (!) mesh as absolutely necessary!" In the case of apical direct fixations, a therapeutically relevant target variable is the elevation angle of vagina (EAV). Established anatomical fixation points are preferable. A safe distance between implants and vulnerable tissue is to be maintained. Mesh-based prolapse repairs are indicated in recurrences, in primary situations, in combined defects of the anterior compartment, in central defects of multimorbid and elderly patients, and above all, when organ preservation is wanted. Native connective tissue structures are to be preserved, strengthened and reconstructed to restore altered functions. Practical skills for highly specialized mesh-based operations as well as effective techniques for complication management should be taught in interdisciplinary specialist courses.

Informed consent checklists for midurethral slings: a common-sense approach

INTRODUCTION AND HYPOTHESIS

Following the US Food and Drug Administration's (FDA's) warning about the use of transvaginal mesh to treat pelvic organ prolapse (POP) and the use of single-incision slings to treat incontinence, the number of lawsuits for medical negligence regarding the use of any polypropylene mesh in the vagina has increased tremendously.

METHODS

This same FDA document did not question the use of polypropylene midurethral slings and polypropylene for sacrocolpopexies. Surprisingly, despite all the evidence and recommendations from respected international scientific societies, we are constantly being called upon by our patients to defend the use of midurethral slings. The most common reasons for the new rash of medicolegal proceedings involving midurethral slings has to do with "breach of duties" resulting from undisclosed postoperative complications on the consent form and/or the lack of information in the medical records confirming that all possible alternative treatment options were presented to and discussed with the patient.

RESULTS

One response to these lawsuits involves the addition of preoperative checklists when performing informed consent with patients electing surgical correction of stress urinary incontinence (SUI).

CONCLUSIONS

This clinical opinion provides an expert clinician's perspectives and legal point of view on this controversial topic and discusses the role of a preoperative checklist supplementary to the standard informed consent form.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification

AIM

To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP).

MATERIALS AND METHODS

This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus.

RESULTS

Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up.

CONCLUSION

Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.

The Disability Impact and Associated Cost per Disability in Women Who Underwent Surgical Revision of Transvaginal Mesh Kits for Prolapse Repair

OBJECTIVES

The aim of this study was to investigate disability impact in patients and cost to the families of patients who have had complications of transvaginal prolapse mesh kits and underwent surgical revision.

METHODS

Patients who developed complications of transvaginal mesh kits for prolapse and who had undergone vaginal prolapse mesh surgical revision/removal in 2009 to 2014 at a single institution were identified by Current Procedural Terminology codes. The group was invited to complete a phone survey pertaining to the initial vaginal mesh used for prolapse surgery utilizing Sheehan Disability Scale (scale 0-10) and Years of life Lived with Disability (YLDs) questionnaires. The data collected were used to estimate the disability and cost analysis. We used our data to estimate the economic and quality-of-life impact of vaginal mesh complications on patients in the United States RESULTS: Sixty-two patients (62/198 [31.2%]) were consented to participate and completed the questionnaires by phone. Extremely disabled patients were 18 (29%) of 62 of whole cases, and 5 (8%) of 62 reported that they had no disability after vaginal mesh surgery. The median for overall disability score after vaginal mesh procedure was 8 (which reflects marked disability on a scale of 0-10). The majority of patients missed a median of 12 months of their school or work because of their mesh complications. Thirty-seven (59.6%) of 62 did not improve after mesh removal. Twenty-one (33.9%) of 62 stated that their family income dropped because of productivity loss related to mesh complications. The mean time between vaginal mesh surgery and mesh removal procedure was 4.7 years. Sheehan Disability Scale scores are significantly correlated with YLDs outcomes. Patients' overall disability score showed a significant correlation with YLDs scores (P < 0.0001).

CONCLUSIONS

Vaginal mesh for prolapse reduction complications had a sustained disability impact that continued despite mesh removal. Likewise, the complications were associated with increased economic burden on the families of the effected individuals and a drop in the family income in more than one third of the families.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a predominant cause in 30% to 80% of these women imposing significant health and economic burden on society and the women affected. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single-incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched: Cochrane Incontinence Specialised Register (including: CENTRAL, MEDLINE, MEDLINE In-Process, ClinicalTrials.gov) (searched 26 June 2014); Embase Classic (January 1947 to Week 25 2014); WHO ICTRP (searched 30 June 2014); reference lists.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible studies and extracted data from included trials.

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. However, a brief economic commentary (BEC) identified three studies suggesting that transobturator may be more cost-effective compared with retropubic. Fewer adverse events occur with employment of a transobturator approach with the exception of groin pain. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

Is a "dragging sensation" a symptom of female pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) commonly presents with a "vaginal lump or bulge" and/or a "dragging sensation." The first symptom correlates strongly with clinical and imaging data. However, a "dragging sensation" may be less specific. Hence, we investigated the predictive value of both symptoms for POP.

METHODS

This was a retrospective study involving archived data sets of women seen between November 2013 and May 2014. All underwent a clinical interview, POPQ examination, and 4D translabial ultrasound (TLUS). The main outcome measure was organ descent on clinical examination and TLUS. Offline analysis for organ descent was undertaken blinded against all other data.

RESULTS

A total of 224 women were assessed. Mean age was 57 (23-84) years. Median parity was 3 (0-7). Ninety-three percent (n=208) were vaginally parous. Fifty-eight percent (n=129) complained of symptoms of prolapse: 49% (n=110) of a vaginal lump, 27% (n=61) of a dragging sensation. Clinically, mean point B anterior (Ba) was -0.86 (-3 to +7.5) cm, mean cervical station (C) was -4.1 (-9 to +8) cm, mean point B posterior (Bp) was -1.1 (-3 to +5) cm. On imaging, mean bladder, uterine, and rectal descent were -8.3 (-68.0 to 34) mm, +18.6 (-56.4 to 46.3) mm, and -5.3 (-39.8 to 36) mm respectively. On univariate analysis, both symptoms were strongly associated with objective prolapse clinically and on TLUS, with "vaginal lump" consistently the stronger predictor.

CONCLUSIONS

The symptom of a "vaginal lump or bulge" was consistently a stronger predictor of objective POP than "dragging sensation." This finding was insensitive to adjustments for potential confounders. However, a "dragging sensation" is clearly a symptom of prolapse.

Towards rebuilding vaginal support utilizing an extracellular matrix bioscaffold

As an alternative to polypropylene mesh, we explored an extracellular matrix (ECM) bioscaffold derived from urinary bladder matrix (MatriStem™) in the repair of vaginal prolapse. We aimed to restore disrupted vaginal support simulating application via transvaginal and transabdominal approaches in a macaque model focusing on the impact on vaginal structure, function, and the host immune response. In 16 macaques, after laparotomy, the uterosacral ligaments and paravaginal attachments to pelvic side wall were completely transected (IACUC# 13081928). 6-ply MatriStem was cut into posterior and anterior templates with a portion covering the vagina and arms simulating uterosacral ligaments and paravaginal attachments, respectively. After surgically exposing the correct anatomical sites, in 8 animals, a vaginal incision was made on the anterior and posterior vagina and the respective scaffolds were passed into the vagina via these incisions (transvaginal insertion) prior to placement. The remaining 8 animals underwent the same surgery without vaginal incisions (transabdominal insertion). Three months post implantation, firm tissue bands extending from vagina to pelvic side wall appeared in both MatriStem groups. Experimental endpoints examining impact of MatriStem on the vagina demonstrated that vaginal biochemical and biomechanical parameters, smooth muscle thickness and contractility, and immune responses were similar in the MatriStem no incision group and sham-operated controls. In the MatriStem incision group, a 41% decrease in vaginal stiffness (P=0.042), a 22% decrease in collagen content (P=0.008) and a 25% increase in collagen subtypes III/I was observed vs. Sham. Active MMP2 was increased in both Matristem groups vs. Sham (both P=0.002). This study presents a novel application of ECM bioscaffolds as a first step towards the rebuilding of vaginal support.

STATEMENT OF SIGNIFICANCE

Pelvic organ prolapse is a common condition related to failure of the supportive soft tissues of the vagina; particularly at the apex and mid-vagina. Few studies have investigated methods to regenerate these failed structures. The overall goal of the study was to determine the feasibility of utilizing a regenerative bioscaffold in prolapse applications to restore apical (level I) and lateral (level II) support to the vagina without negatively impacting vaginal structure and function. The significance of our findings is two fold: 1. Implantation of properly constructed extracellular matrix grafts promoted rebuilding of level I and level II support to the vagina and did not negatively impact the overall functional, morphological and biochemical properties of the vagina. 2. The presence of vaginal incisions in the transvaginal insertion of bioscaffolds may compromise vaginal structural integrity in the short term.

Uterine preservation for advanced pelvic organ prolapse repair: Anatomical results and patient satisfaction

OBJECTIVE

The aims of the current study were to evaluate outcomes and patient satisfaction in cases of uterine prolapse treated with vaginal mesh, while preserving the uterus.

MATERIALS AND METHODS

This is a retrospective cohort study that included all patients operated for prolapse repair with trocar-less vaginal mesh while preserving the uterus between October 2010 and March 2013. Data included: patients pre-and post-operative symptoms, POP-Q and operative complications. Success was defined as prolapse < than stage 2. A telephone survey questionnaire was used to evaluate patient's satisfaction.

RESULTS

Sixty-six patients with pelvic organ prolapse stage 3, including uterine prolapse of at least stage 2 (mean point C at+1.4 (range+8-(-1)) were included. Mean follow-up was 22 months. Success rate of the vaginal mesh procedure aimed to repair uterine prolapse was 92% (61/66), with mean point C at -6.7 (range (-1) - (-9)). No major intra-or post-operative complication occurred. A telephone survey questionnaire was conducted post-operatively 28 months on average. Ninety-eight percent of women were satisfied with the decision to preserve their uterus. Eighteen patients (34%) received prior consultation elsewhere for hysterectomy due to their prolapse, and decided to have the operation at our center in order to preserve the uterus.

CONCLUSIONS

Uterine preservation with vaginal mesh was found to be a safe and effective treatment, even in cases with advanced uterine prolapse. Most patients prefer to keep their uterus. Uterus preservation options should be discussed with every patient before surgery for pelvic organ prolapse.

Mesh in POP surgery should be based on the risk of the procedure, not the risk of recurrence

The still unfolding story of mesh use in surgery for pelvic organ prolapse (POP) offers insights into the factors that influence how we interpret evidence in assessing new technology. Our adoption of mesh in prolapse surgery was influenced by a paradigm shift from treating to preventing recurrent prolapse. This shift is largely unsupported by data and fails to account for the added risk associated with mesh use. This commentary explores unconscious factors that influence our interpretation of innovation and proposes a new approach to evaluating new surgical technologies that balances benefit and risk. Counseling patients about treatments using the benefit-risk approach offers a more balanced perspective. Using a formal benefit-risk assessment in the scientific evaluation of treatments will also provide a more balanced approach that supports the scientific process and patients who undergo treatment.

Risk Factors for Mesh Exposure after Transvaginal Mesh Surgery

Background:

Mesh exposure after surgery continues to be a clinical challenge for urogynecological surgeons. The purpose of this study was to explore the risk factors for polypropylene (PP) mesh exposure after transvaginal mesh (TVM) surgery.

Methods:

This study included 195 patients with advanced pelvic organ prolapse (POP), who underwent TVM from January 2004 to December 2012 at the First Affiliated Hospital of Chinese PLA General Hospital. Clinical data were evaluated including patient's demography, TVM type, concomitant procedures, operation time, blood loss, postoperative morbidity, and mesh exposure. Mesh exposure was identified through postoperative vaginal examination. Statistical analysis was performed to identify risk factors for mesh exposure.

Results:

Two-hundred and nine transvaginal PP meshes were placed, including 194 in the anterior wall and 15 in the posterior wall. Concomitant tension-free vaginal tape was performed in 61 cases. The mean follow-up time was 35.1 ± 23.6 months. PP mesh exposure was identified in 32 cases (16.4%), with 31 in the anterior wall and 1 in the posterior wall. Significant difference was found in operating time and concomitant procedures between exposed and nonexposed groups (F = 7.443, P = 0.007; F = 4.307, P = 0.039, respectively). Binary logistic regression revealed that the number of concomitant procedures and operation time were risk factors for mesh exposure (P = 0.001, P = 0.043).

Conclusion:

Concomitant procedures and increased operating time increase the risk for postoperative mesh exposure in patients undergoing TVM surgery for POP.

The feasibility of transvaginal robotic surgery in the repair of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP), the descent of one or more pelvic organs, occurs in an estimated 40 to 60% of parous women. Conventional transvaginal surgery for POP has been plagued with high failure rates. The purpose was to determine the safety and feasibility of robotic transvaginal POP surgery.

METHODS

The da Vinci Surgical Robot, SI was used in the POP surgical procedures. There were two cadavers (aged 18 and 78 years of age; BMI 17.2 and 19.2 respectively). POP-Q scores before intervention were stage 1 for both cadavers.

RESULTS

The visualization of anatomical landmarks and the placement of sutures at these locations were successful.

CONCLUSION

Robotic transvaginal POP is a feasible option for POP surgery. Further studies are warranted to determine the role of robotic transvaginal POP repair.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications

OBJECTIVE

The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications.

METHODS

This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh.

RESULTS

Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions.

CONCLUSIONS

In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.